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A 


TEXT-BOOK  OF  SURGERY 


FOR  STUDENTS  AND  PRACTITIONERS 


BY 

GEORGE  EMERSON  BREWER,  A.M.,  M.D. 

PROFESSOR  OF  SURGERY  AT  THE  COLLEGE  OF  PHYSICIANS  AND  SURGEONS,  COLUMBIA   UNIVERSITY,  NEW  YORK; 

SURGICAL    DIRECTOR    OF    THE    PRESBYTERIAN     HOSPITAL;     CONSULTING    SURGEON    TO    THE    ROOSEVELT 

HOSPITAL,    THE    CITY    HOSPITAL,     THE    MUHLENBERG    HOSPITAL    OF    PLAINFIELD,    N.    J.,    AND    THE 

PERTH    AMBOY     CITY    HOSPITAL;    FELLOW    OF   THE    AMERICAN     SURGICAL    ASSOCIATION,     OF 

THE    AMERICAN    ASSOCIATION    OF    GENITO-URINARY    SURGEONS,    OF    THE    NEW     YORK 

ACADEMY   OF    MEDICINE,    AND    OF  THE    NEW    YORK  SURGICAL    SOCIETY;  MEMBRE 

DE    LA  SOCIETE    INTERNATIONAL    DE    CHIRURGJE;    MEMBRE    DE  LA   SOCIETE 

INTERNATIONAL    DE    UROLOGIE:    MEMBRE    CORRESPONDENT    DE 

L'ASSOCIATION    FRANC  AISE     d' UROLOGIE 

ASSISTED  BY 

ADRIAN  V.  S.  LAMBERT,  M.D. 

ASSOCIATE  PROFESSOR  OF  SURGERY,  COLLEGE  OF  PHYSICIANS  AND  SURGEONS,   COLUMBIA  UNIVERSITY; 
ATTENDING  SURGEON  TO  THE  PRESBYTERIAN  HOSPITAL 

AND  BY 

MEMBERS  OF  THE  SURGICAL  TEACHING  STAFF  OF 
COLUMBIA  UNIVERSITY 


THIRD  AND  ENLARGED  EDITION,   THOROUGHLY  REVISED   AND 

REWRITTEN 

ILLUSTRATED   WITH    500  ENGRAVINGS  IN  THE   TEXT  AND  23  PLATES 
IN    COLORS  AND   MONOCHROME 


LEA  &   FEBIGER 

PHILADELPHIA    AND    NEW    YORK 
1915 


Entered  according  to  the  Act  of  Congress,  in  the  year  1915,  by 

LEA  &  FEBIGER, 
in  the  Office  of  the  Librarian  of  Congress.     All  rights  reserved. 


IVs" 


COLLABORATORS 

HUGH   AUCHINCLOSS,  M.D. 
SIDNEY  R.  BURNAP,  M.D. 
WILLIAM  A.  CLARKE,   M.D. 
JAMES  A.  CORSCADEN,  M.D. 
WILLIAM   DARRACH,  M.D. 
JOHN  A.   McCREERY,  M.D. 
FRANK  S.  MATTHEWS,   M.D. 
CHARLES  H.   PECK,  M.D. 
EUGENE  H.  POOL,  M.D. 
JAMES  I.   RUSSELL,  M.D. 
FRANCIS  J.  SLOANE,  M.D. 
FORDYCE  B.  St.  JOHN,  M.D. 
ALLEN  0.  WHIPPLE,  M.D. 
ARMITAGE  WHITMAN,  M.D. 


TO 

ROBERT  F.  WEIR,  M.D.,  Hon.  F.R.C.S.  Eng., 

PROFESSOR  OF  SURGERY,  COLUMBIA   UNIVERSITY,  ETC., 

A  MASTER  OF  SURGERY,  A  SCHOLARLY   TEACHER,  A   SUCCESSFUL 

PRACTITIONER,  MY   HONORED   CHIEF  AND 

VALUED   FRIEND, 

THIS  VOLUME  IS  AFFECTIONATELY   DEDICATED 

BY   THE    AUTHOR. 


PREFACE  TO  THE  THIRD  EDITION. 


The  demand  for  a  new  edition  has  been  utilized  to  the  fullest 
extent  by  subjecting  the  entire  work  to  a  thoroughgoing  revision. 
This  has  resulted  not  only  in  the  complete  rewriting  of  every  chapter, 
with  consequent  enlargement,  but  also  in  the  addition  of  many  new 
ones.  The  book,  in  a  word,  is  virtually  a  new  one,  and  it  is  confidently 
hoped  that  it  will  accomplish  its  purpose  of  presenting  clearly  every 
phase  of  modern  surgery. 

To  reach  this  object  with  the  maximum  of  certainty,  the  author 
has  availed  himself  of  the  help  of  a  number  of  colleagues  on  the  Surgical 
Staff  of  Columbia  University.  The  plan  followed,  as  far  as  possible, 
was  to  have  the  chapters  upon  subjects  in  which  notable  progress  has 
been  made  revised  and  in  some  instances  largely  rewritten  by  members 
of  the  teaching  staff  of  the  Medical  School  who  had  to  do  directly 
with  the  instruction  in  these  subjects.  Thus  the  chapters  on  Surgical 
Pathology  have  been  revised  by  Dr.  Clarke ;  the  chapter  on  Anesthesia 
by  Dr.  Whipple;  that  on  Bone  Infection  by  Dr.  Russell;  Dr.  Pool 
revised  the  subjects  of  shock  and  allied  conditions,  heart  and  peri- 
cardium, and  has  entirely  rewritten  the  section  on  goitre.  The  author 
is  indebted  to  Dr.  Mathews  for  rewriting  the  sections  dealing  with 
hare-lip  and  cleft  palate;  to  Dr.  Whitman  for  revising  the  chapter 
on  Deformities;  to  Dr.  McCreery  for  that  on  the  muscles,  tendons, 
and  burs?e;  to  Dr.  Sloane  for  the  one  on  the  bladder,  urethra,  and 
male  genital  organs;  and  to  Dr.  Burnap  for  the  chapter  dealing  with 
hernia.  Dr.  Darrach  revised  the  subjects  of  fractures  and  dislocations, 
and  added  much  to  the  modern  operative  treatment.  Dr.  Corscaden 
revised  the  chapter  on  Amputations  and  largely  rewrote  the  chapter 
on  Diseases  of  the  Joints.  Dr.  Whipple  and  Dr.  St.  John  have  added 
an  important  chapter  on  Postoperative  Treatment,  and  Dr.  Auchin- 
closs,  in  addition  to  revising  the  chapter  on  the  Lymphatic  System, 
has  brought  the  important  subject  of  hand  infections  and  cellulitis 
up  to  date.  Dr.  Peck  revised  the  subjects  of  appendicitis,  peritonitis, 
and  diseases  of  the  large  intestine,  to  make  them  correspond  with  his 


vin  PREFACE   TO   THE   THIRD  EDITION 

lectures  and  clinical  teaching.  To  Dr.  Lambert  the  author  is  indebted 
not  only  for  a  careful  revision  of  the  chapters  on  Surgical  Technic, 
Injuries  and  Diseases  of  the  Nerves,  Head,  Brain,  and  Spinal  Cord, 
but  also  for  assuming  in  large  part  the  duties  of  Editor. 

The  author's  personal  revisions  have  been  limited  to  the  chapters 
dealing  with  the  surgery  of  the  face,  neck,  mouth,  pharynx,  larynx, 
pleura,  lung,  mammary  gland,  stomach  and  duodenum,  liver  and 
biliary  passages,  pancreas,  spleen,  kidney  and  ureter. 

Many  of  the  subjects  were  completely  rewritten,  and  considerable 
extra  space  had  to  be  allotted  to  include  the  advanced  ideas  of 
pathology  and  treatment  which  have  been  developed  since  the  pub- 
lication of  the  second  edition.  Particularly  was  this  the  case  in 
dealing  with  hand  infections  and  cellulitis,  with  goitre,  and  with 
joint  diseases. 

Many  new  illustrations  have  been  introduced  from  photographs 

from  the  Record  Room  and  Surgical  Laboratory  of  the  Presbyterian 

Hospital,  also  an  increased  number  of  full-page  colored  plates  have 

been  reproduced  from   a  series  of  Lumiere  photographs  of  clinical 

conditions. 

G.  E.  B. 
New  Yobk,  1915. 


CONTENTS. 


CHAPTER   I. 
Infection  Considered  in  its  Surgical  Relations 17 

CHAPTER   II. 
Inflammation 31 

CHAPTER   III. 
Acute  Infectious  Surgical  Diseases 38 

CHAPTER   IV. 
Chronic  Infectious  Surgical  Diseases 58 

CHAPTER  V. 
Tumors 74 

CHAPTER  VI. 
Shock  and  Allied  Conditions  101 

CHAPTER  VII. 

Surgical  Technic 128 

CHAPTER  VIII. 
Anesthesia 153 

CHAPTER   IX. 

Treatment  of  Postoperative  Conditions 174 

CHAPTER  X. 
Injuries  and  Diseases  of  the  Skin  and  Subcutaneous  Tissues  .     189 

CHAPTER  XI. 

The  Surgery  of  the  Pericardium  and  Heart 241 


x  CONTENTS 

CHAPTER    XII. 
Injuries  and  Diseases  of  the  Lymphatic  System 278 

CHAPTER    XIII. 
Injuries  and  Diseases  of  the  Muscles,  Tendons,  Fascle  and  Bunas    .     294 

CHAPTER   XIV. 
Injuries  and  Diseases  ok  the  Xerves 303 

CHAPTER   XV. 
Injuries  and  Diseases  ok  Head  and  Brain 324 

CHAPTER    XVI. 
Injuries  and  Diseases  of  the  Spine 374 

CHAPTER   XVII. 

Injuries   and    Diseases   of   the    Face    and    Neck,    Oral,    Nasal,    and 

Pharyngeal  Cavities 387 

CHAPTER   XVIII. 
Injuries  and  Diseases  of  the  Thorax,  Pleura,  and  Lung  ....     459 

CHAPTER   XIX. 
Malformations  and  Diseases  of  the  Mammary  Gland 483 

CHAPTER    XX. 

Injuries  of  the  Abdomen 500 

CHAPTER    XXI. 
Diseases  of  the  Abdomen 507 

CHAPTER   XXII. 

Diseases  and  Injuries  of  the  Kidneys  and  Ureters 600 

CHAPTER  XXIII. 
Injuries  and  Diseases  of  the  Bladder  and  Urethra G46 

CHAPTER    XXIV. 
Injuries  and  Diseases  of  the  Penis  and  Scrotum 688 


CO  NT R NTS  xi 

CHAPTER  XXV. 
Injuries  and  Diseases  of  the  Testicle,  Seminal  Vesicle,  and  Prostate     699 

CHAPTER  XXVI. 

Injuries  and  Diseases  of  the  Rectum  and  Anus 723 

CHAPTER   XXVII. 
Diseases  of  Bone 741 

CHAPTER   XXVIIT. 
Injuries  and  Diseases  of  Joints 766 

CHAPTER   XXIX. 
Fractures '    806 

CHAPTER   XXX. 
Dislocations 873 

CHAPTER  XXXI. 
Hernia 909 

CHAPTER   XXXII. 
Amputations 944 

CHAPTER  XXXIII. 
Deformities  and  Their  Correction 964 


SURGERY. 


CHAPTER  I. 
INFECTION  CONSIDERED  IN  ITS  SURGICAL  RELATIONS. 

INTRODUCTION. 

Surgery  is  that  branch  of  the  healing  art  directed  toward  the 
remedying  of  injuries,  deformities,  and  many  other  morbid  conditions 
by  mechanical  operations. 

Such  a  conception  of  surgery  differentiates  it  from  the  art  of 
medicine.  So  intimately  related,  however,  are  the  two  that  it  is 
almost  impossible  to  draw  a  sharp  dividing  line  between  them. 
Therefore,  in  the  broader  sense,  surgery  may  be  said  to  include  the 
subjects  of  infection,  inflammation,  injuries,  new  growths,  foreign 
bodies,  malformations,  deformities,  and  the  relief  of  pain,  with  the 
various  methods  of  operative  and  therapeutic  procedure  which  their 
betterment  entails. 

The  phenomena  of  infection  and  inflammation,  occurring,  as  they 
do,  more  commonly  than  all  others  in  surgery,  being  of  fundamental 
importance  and  far  reaching  in  their  relations  to  other  surgical 
aspects,  it  is  essential  that  any  exposition  of  the  subject  of  surgery 
must  be  preceded  by  a  thorough  comprehension  of  these  phenomena. 

Although  the  occurrence  of  inflammation  is  often  aided  by  the 
existence  of  predisposing  agencies,  the  direct  or  exciting  causes  are 
usually  to  be  found  under  the  heads,  direct  violence  and  physical 
irritation,  chemical  irritants,  and  microorganisms. 

Microorganisms  are  distributed  widely  in  air,  soil,  and  water, 
but  it  is  among  the  habitations  of  man,  where  the  conditions  for 
their  growth  and  development  are  especially  suitable,  that  they  are 
most  numerous.  For  the  most  part,  they  are  harmless  species; 
but  pathogenic  forms  may  occasionally  be  found,  especially  in 
localities  where  the  discharges  of  diseased  animals  have  been  allowed 
to  collect.  Thus,  while  the  conditions  here  are  unfavorable  for 
the  growth  of  most  harmful  species,  it  has  been  shown  that  certain 
pathogenic  bacteria  have  their  primary  habitat  in  soil;  while  others 
are  capable,  at  any' rate  during  part  of  their  existence,  of  finding  a 
nidus  there. 


IS      INFECTION  CONSIDERED  IN  ITS  SURGICAL  RELATIONS 

So  far  as  we  know,  then,  with  few  exceptions,  micro-organisms 
whose  natural  habitat  is  in  the  soil  or  water,  are  not  under  normal 
conditions  harmful  to  man,  for  they  are  present  in  greater  or  less 
numbers  upon  the  exposed  cutaneous  or  mucous  surfaces  of  the 
body,  sometimes  serving  useful  functions,  as  do  those  in  the 
intestines. 

Experiments  by  Nuttall  and  Schottelius  show  that  the  healthy 
animal  is  born  germ-free.  At  birth,  however,  it  is  at  once  introduced 
into  a  world  of  bacteria  that  fall  upon  the  skin  and  gain  entrance 
to  the  respiratory  passages  and  alimentary  canal  through  air  and 
food.  In  a  short  time  they  may  be  found  in  various  parts  of  the 
body,  so  that  each  part  ultimately  becomes  a  regular  habitat  for  a 
number  of  species. 

Notwithstanding,  however,  the  occurrence  of  bacteria  in  these 
situations  in  great  numbers,  they  do  not  often  gain  entrance  into 
the  body  tissues,  so  that  under  normal  conditions  the  blood  and 
viscera  have  been  considered  germ-free.  It  has,  however,  been 
urged  by  Adami  and  Ford  that  bacteria  reach  not  alone  the  deeper 
structures  of  the  intestine  under  what  appear  to  be  normal  conditions, 
but  commonly  also  invade  the  blood  of  the  portal  circulation  and 
the  liver  and  kidneys  during  life. 

Whenever  bacteria  do  find  their  way  into  the  body,  the  condi- 
tions are  usually  so  unsuitable  for  their  existence  that  they  are  soon 
destroyed.  Against  such  incursions  the  body  is  guarded  in  various 
ways.  Of  the  defensive  arrangements  which  normally  exist  at  the 
various  portals  of  entry,  some  are  partly  mechanical  by  reason  of  the 
anatomic  structure  of  the  part.  Thus  the  thick  cutaneous  covering 
is  impenetrable  to  most  bacteria;  the  same  is  equally  true  for  the 
stratified  squamous  layer  of  the  mouth,  esophagus,  and  vagina. 
While  the  cylindric  epithelium  covering  other  mucous  surfaces  is 
doubtless  less  efficient,  it  should  be  remembered  that  they  are  so 
situated  as  to  be  less  exposed  to  injury. 

There  are  certain  situations,  such  as  the  tonsils  and  lymphatic 
apparatus  of  the  gut,  which  are  especially  liable  to  bacterial  invasion 
on  account  of  their  delicate  covering;  but  there  is  abundant  reason 
to  suppose,  as  will  be  seen  shortly,  that  they  are  endowed  with 
vital  protective  properties. 

In  addition  to  these  mechanical  defences  are  the  antibacterial 
qualities  of  the  secretions  on  mucous  surfaces.  Some  of  the  prop- 
erties depend  on  the  chemical  action  of  the  gastric  juice;  some 
partly  on  the  antagonism  offered  to  invaders  by  the  normal  flora 
of  the  part;  while  still  others  depend  largely  upon  the  germicidal 
qualities  of  the  secretion. 

But  notwithstanding  these  protective  factors,  bacteria  do  some- 
times penetrate  the  normal  body  coverings,  and  this  may  especially 
occur  whenever  these  coverings  are  injured,  even  if  ever  so  slightly. 
Having  gained  entrance  to  the  tissues  they  may  be  engulfed  by 


PORTALS  OF  ENTRY  19 

leukocytes  or  destroyed  by  tissue  fluids.     Escaping,  they  may  be 
arrested  in  the  regional  lymph  nodes. 

If  bacteria  do  reach  the  blood,  they  again  have  to  contend  with 
the  body  fluids  and  leukocytes.  It  is  evident  that  in  health  the 
body  is  protected  abundantly  against  ordinary  bacterial  invasion, 
but  there  are  conditions  in  which  the  strongest  and  healthiest 
body  is  unable  to  offer  adequate  resistance;  obviously,  therefore, 
it  is  usually  when  the  vital  resistance  of  the  body  cells  has  been 
lowered  that  virulent  bacteria  overcome  the  natural  safeguards  to 
infection. 

PORTALS  OF  ENTRY. 

Bacteria  may  gain  entrance  to  the  body  tissues  in  several  different 
ways.  According  to  the  portal  of  entry,  differences  not  only  in 
the  susceptibility  of  the  host  but  also  in  the  lesions  and  symptoms 
of  the  disease  will  be  noted.  Many  surgically  important  bacteria 
may  gain  entrance  through  any  portal  and  induce  infection  in  any 
part  of  the  body,  but  some  are  restricted  to  certain  modes  of  entrance, 
as  in  the  case  of  the  tetanus  bacillus.  For  the  most  part,  micro- 
organisms reach  the  interior  of  the  body  from  the  skin  and  mucous 
surfaces.  It  is  very  improbable  that  bacteria  present  upon  the  skin 
can  penetrate  this  tissue  when  uninjured.  It  is  true,  however, 
that  often  they  appear  to  reach  the  interior  of  the  body  from  what 
seems  to  be  an  uninjured  skin  surface,  but  in  these  cases  it  is  probable 
that  the  skin  injury  has  been  overlooked  by  reason  of  its  smallness. 
It  is  only  very  rarely  that  bacteria  directly  gain  entrance  into  the 
general  blood  current.  They  ordinarily  reach  it  through  the  atria, 
which  have  been  mentioned. 

External  Sources. — The  bacteria  derived  from  without  the  body  are 
those  chiefly  concerned  in  the  infection  of  wounds  and  many  other 
primary  surgical  infections.  They  usually  gain  access  to  wounds 
through  contact  with  infected  objects.  Air  infection  is  relatively 
unimportant,  and  here  the  bacteria  usually  occur  as  clumps  attached 
to  particles  of  dust,  so  that  in  a  perfectly  quiet  atmosphere,  as  in 
a  closed  room,  these  particles  containing  bacteria  rapidly  settle 
upon  underlying  objects.  It  is  a  well-known  fact  that  particles 
including  bacteria  are  not  detached  from  moist  surfaces  even  by 
strong  currents  of  air. 

Among  those  of  surgical  importance  which  are  conveyed  through 
external  objects  are  Streptococcus  pyogenes,  Staphylococcus  pyogenes 
aureus,  Staphylococcus  pyogenes  albus,  Bacillus  coli  communis, 
Bacillus  pyocyaneus,  Bacillus  proteus,  Diplococcus  lanceolatus, 
Bacillus  anthracis,  Bacillus  tetani,  Bacillus  aerogenes  capsulatus, 
Bacillus  tuberculosis,  Micrococcus  gonorrhea,  and  a  host  of  others. 

The  relation  of  insects  to  the  spread  of  infectious  agents  has 
recently  been  emphasized  by  Nuttall.  Considerable  evidence  has 
been  accumulated  in  the  past  few  years  which  clearly  indicates 


20     INFECTION  CONSIDERED  IN  ITS  SURGICAL  RELATIONS 

that  insects  may  not  only  carry  from  place  to  place  disease-produc- 
ing micro-organisms,  but  they  may  also  be  concerned,  directly  or 
indirectly,  in  the  inoculation  of  pathogenic  micro-organisms. 

Interesting  experiments  made  by  Schimmelbusch  and  others 
studying  the  rapidity  of  absorption  of  bacteria  in  wounds,  show 
that  they  are  absorbed  within  a  very  short  time  by  lymph  and 
bloodvessels  from  fresh  bleeding  wounds.  Further,  it  has  been 
shown  that  as  soon  as  a  coagulum  has  been  formed  on  the  surface 
of  a  wound  the  conditions  are  changed,  and  particles  like  bacteria 
are  no  longer  quickly  transported  into  the  blood  and  lymph  circu- 
lation. The  surface  of  a  healthy  granulating  wound  affords  great 
resistance  to  bacterial  invasion,  almost  as  much  as  an  intact  exposed 
surface  of  the  body.  Slight  injuries,  however,  such  as  probing, 
removing  the  dressing,  and  other  manipulations  which  may  convert 
the  ganulating  wound  into  a  recent  wound,  favor  the  absorption 
of  bacteria. 

Bacteria  of  the  Skin. — Since  the  skin  is  exposed  to  contamination 
from  the  dust  and  other  sources,  it  is  evident  that  there  is  scarcely 
any  limit  to  the  number  of  bacterial  species  which  may  be  found 
upon  cutaneous  surfaces.  Most  of  the  organisms  ordinarily  found 
are  such  as  may  be  found  in  the  air  or  upon  external  objects.  They 
are  principally  cocci,  but  there  are  great  variations  in  different 
cases  as  to  the  kind  and  numbers.  Sometimes  one  species  far 
outnumbers  the  rest.  Further,  the  kind  and  number  of  bacteria 
found  upon  exposed  parts  of  the  skin  vary  considerably,  according 
to  the  habits  and  occupation  of  the  individual.  Certain  organisms 
which  are  met  with  only  exceptionally  in  most  persons,  are  found 
commonly  on  the  hands  of  persons  who  handle  or  come  into 
proximity  with  infected  cases. 

For  many  of  the  facts  relating  to  the  bacteriology  of  the  skin 
we  are  indebted  to  Welch,  who  not  only  called  attention  to  the 
inconstant  characters  of  the  bacteria  of  the  skin  but  also  insisted 
upon  the  great  regularity  with  which  Staphylococcus  epidermidis 
albus  may  be  obtained  in  cultures  taken  from  the  skin,  so  that  this 
organism  may  be  regarded  as  a  normal  inhabitant  in  this  situation. 
It  is  also  regularly  present  in  the  layers  of  epidermis  along  hair- 
shafts  deeper  than  can  be  reached  by  any  practical  means  of  cutane- 
ous disinfection.  After  complete  sterilization  of  cutaneous  surfaces, 
so  that  scrapings  are  sterile,  the  presence  of  this  white  coccus  can 
still  be  demonstrated  on  sutures  passed  through  the  skin  and  in 
excised  pieces  of  skin. 

Staphylococcus  epidermidis  albus  is  usually  innocuous.  It  is 
frequently  present  in  aseptic  wounds  of  the  skin  without  inducing 
suppuration  or  any  untoward  reactions.  However,  it  may  be  the 
cause  of  disturbances  characterized  especially  by  elevation  of  tem- 
perature and  moderate  suppuration.  It  is  a  common  excitant  of 
stitch  abscess.     Among  other  bacteria  which  may  be  present  upon 


PORTALS  OF  ENTRY  21 

the  skin  are  Streptococcus  pyogenes,  Staphylococcus  pyogenes  aureus 
and  albus,  Bacillus  pyocyaneus,  and  Bacillus  coli  communis. 

Skin  contaminated  with  the  soil,  which,  as  is  well  known,  contains 
in  many  situations  abundant  bacilli  of  tetanus  and  of  malignant 
edema,  is  likely  to  contain  these  bacteria.  This  contamination 
relates  especially  to  the  hands  and  exposed  skin. 

The  smegma  bacillus  may  be  considered  in  connection  with  skin 
bacteria.  This  organism  is  usually  present  in  the  smegma  and 
may  be  found  about  the  perineum.  Attention  is  called  to  it  par- 
ticularly on  account  of  its  resemblance  in  morphology  and  tinctorial 
reactions  to  the  tubercle  bacillus.  It  has  been  mistaken  for  Bacillus 
tuberculosis  in  the  examination  of  urine  and  of  secretions  and 
exudates  from  the  external  genitals  and  the  anus.  Although  smegma 
bacilli  are  found  to  be  present  with  pathogenic  bacteria  in  lesions 
about  these  parts,  they  do  not  possess  pathogenic  activities  for  man. 

Many  bacteria  are  attached  to  the  hair,  and  particles  containing 
bacteria  may  readily  be  deposited  from  the  hair  upon  wounds. 
They  are,  for  the  most  part,  identical  with  those  found  on  the  skin. 

Internal  Sources. — The  way  is  open  for  the  access  of  bacteria 
into  mucous  membranes;  they  communicate  with  the  outer  world 
through  the  external  orifices  of  the  body.  The  relatively  favorable 
conditions  here  present  for  bacterial  growth  are  counteracted  in 
large  part  by  various  mechanical  and  chemical  influences  which 
prevent  the  survival  of  most  bacteria  which  may  enter.  There  are, 
however,  many  bacteria  which  may  multiply  or  persist  for  a  long 
time,  particularly  those  of  the  alimentary  canal  and  of  the  upper 
respiratory  tract.  Among  this  number  there  are  some  which  may  be 
pathogenic,  but  which  under  ordinary  circumstances  are  not  harmful. 

Mouth  and  Pharynx. — Although  the  conditions  in  the  mouth  and 
throat  are  more  favorable  for  the  prolonged  existence  of  many 
bacteria  than  upon  other  exposed  mucous  membranes,  very  few  of 
the  large  number  which  reach  those  parts  persist  there.  Most  of 
them  either  pass  into  the  stomach  and  intestines  or  are  destroyed 
in  the  mouth.  Present  in  the  mouth  and  pharynx  are  saprophytes, 
also  many  streptococci,  staphylococci,  and  pneumococci.  Certain  of 
these  organisms  are  frequent  in  dental  caries. 

The  following  pathogenic  bacteria  have  also  been  found  repeat- 
edly in  the  healthy  mouth:  Streptococcus  pyogenes,  Staphylococcus 
pyogenes  aureus,  Staphylococcus  pyogenes  albus,  Micrococcus 
tetragenus,  Diplococcus  lanceolatus,  Bacillus  pneumoniae  of  Fried- 
lander,  Bacillus  coli  communis,  Bacillus  diphtherise,  Bacillus  proteus, 
and  others.  The  mouth  and  adjacent  parts  are  the  most  frequent 
portals  of  entry  of  the  organism  of  actinomycosis;  it  is  especially 
liable  to  lodge  in  or  near  carious  teeth. 

Respiratory  Passages. — With  inspiration,  bacteria  on  dust  reach 
the  upper  respiratory  tract.  Thompson  and  Hewlet  estimate  that 
from  fifteen  hundred  to  fourteen  thousand  bacteria  are  inspired 


22     INFECTION  CONSIDERED  IN  ITS  SURGICAL  RELATIONS 

every  hour,  the  great  majority  of  which  are  arrested  in  the  nasal 
cavities. 

Among  the  pathogenic  organisms  which  have  been  found  in  the 
nasal  cavities  may  be  mentioned  the  common  pyogenic  cocci,  Diplo- 
coccus  lanceolatus,  Meningococcus,  Bacillus  diphtheria*,  Bacillus 
tuberculosis,  Bacillus  aerogenes  capsnlatns,  and  Friedlander's 
pneumobacillus.  The  presence  of  capsulated  bacilli  in  the  nose  is 
of  considerable  interest,  for  organisms  of  this  class  have  been  found 
with  especial  frequency  in  cases  of  ozena. 

Bacteria  may  be  present  in  the  larynx  and  bronchi  in  health, 
but  in  small  numbers.     Usually  the  healthy  lung  is  considered  free. 

Stomach  and  Intestines. — Under  ordinary  conditions  of  life  bacteria 
make  their  appearance  shortly  after  birth  in  all  parts  of  the  digestive 
tract.  In  many  animals  Bacillus  coli  communis,  or  its  near  allies, 
seems  to  be,  as  in  man,  the  chief  obligatory  form. 

The  relative  numbers  of  Bacillus  coli  communis  in  different 
portions  of  the  alimentary  canal  have  been  variously  estimated. 
The  observations  of  Gilbert  and  Dominici  and  those  of  dishing  and 
Livingwood  indicate  that  there  is  a  gradual  rise  in  the  number 
from  the  duodenum  to  the  ileocecal  valve,  at  which  situation  the 
maximum  is  noted.  When  the  large  bowel  is  reached,  there  is  a 
marked  diminution  in  the  number. 

The  main  sources  of  the  bacteria  of  the  stomach  and  intestines  are 
the  ingesta  and  from  dust.  From  these  sources  great  numbers  and 
varieties  are  introduced  into  the  alimentary  canal,  but,  as  is  true 
of  exposed  mucous  surfaces,  only  a  limited  number  of  species  are 
capable  of  prolonged  existence  here.  The  gastric  juice  may  kill 
many  of  those  which  enter  the  stomach,  but  there  are  many  which 
resist  its  action.  Indeed,  some  can  grow  in  the  human  stomach. 
Emphasis  has  been  laid  upon  the  presence  of  the  Boas-Oppler 
bacillus  on  account  of  its  supposed  diagnostic  value  in  carcinoma 
of  the  stomach,  but  its  presence  has  been  shown  to  depend  upon 
conditions  more  common  in  other  gastric  diseases. 

The  variety  of  bacteria  in  the  intestines  is  large;  the  presence  of 
some  is  only  accidental  or  transient,  while  others  are  there  with 
such  frequency  as  to  merit  special  notice.  The  colon  bacillus  has 
already  been  referred  to.  Pyogenic  cocci  are  rarely  absent  from 
the  intestines,  where  they  may  be  present  in  such  small  numbers 
as  to  escape  detection,  but  the  great  frequency  with  wrhich  they 
may  be  found  in  perforative  peritonitis  is  significant.  Bacillus 
proteus,  Bacillus  pyocyaneus,  Bacillus  tetani,  Diplococcus  lanceo- 
latus, Bacillus  aerogenes  capsulatus,  and  others  have  also  been 
found. 

Under  normal  conditions  the  intestinal  bacteria  are  found  only  a 
short  distance  in  the  common  bile-duct;  but  any  alteration  from 
the  normal,  such  as  mechanical  impediment  to  the  outflow  of  bile, 
change  in  the  composition  of  the  bile,  or  other  perturbation  in  the 


THE  BACTERIAL  EXCITANT  AND  HOST  23 

physiology  <>t'  secretion,  may  be  followed  by  an  ascending  infect  ion 
of  the  ducts  or  gall-bladder.  The  relation  of  the  origin  of  many 
cases  of  cholecystitis  and  cholelithiasis  to  this  form  of  infection  by 
the  colon  and  typhoid  bacilli  has  been  firmly  established. 

Genito-urinary  Tract. — It  has  been  shown  repeatedly  that  the 
anterior  portion  of  the  healthy  male  urethra  contains  bacteria. 
These  are  abundant  and  varied  in  the  fossa  naviculars,  and  diminish 
rapidly  in  number  and  kind  toward  the  posterior  part  of  the  urethra. 
Urethral  bacteria  are  usually  present  in  urine  voided  after  sterilization 
of  the  meatus  and  fossa,  even  in  the  urine  passed  toward  the  end  of 
micturition.  Among  the  non-pathogenic  and  pathogenic  bacteria 
found  in  healthy  urethras  may  be  mentioned  the  smegma  bacillus, 
and  Bacillus  coli  communis. 

It  cannot  be  said  that  the  question  has  definitely  been  settled 
as  to  whether  the  bacteria  of  cystitis  are  usually  those  normally 
present  in  the  urethra  or  those  directly  introduced  from  the  meatus. 
The  bladder  urine  in  health  is  germ-free. 

The  female  urethra  contains  micro-organisms,  and  the  anatomic- 
conditions  are  much  more  favorable  than  in  the  male  for  their 
passage  into  the  bladder.  The  vagina  also  contains  bacteria  in 
varying  number  and  kind.  Pathogenic  species  are  found  only 
occasionally.  The  so-called  "vaginal  saprophytes"  are  the  bacteria 
more  constantly  present  and  are  evidently  harmless.  The  occasional 
presence  of  pathogenic  organisms  is  usually  transitory;  they  may, 
however,  persist  for  a  variable  time  as  harmless  parasites.  The 
experiments  of  Schluter  and  Witte  on  the  effect  of  acid  on  certain 
bacteria,  including  pyogenic  streptococci,  and  staphylococci,  show 
that  the  percentage  of  acid  usually  present  in  the  vagina  may  inhibit 
their  growth.  Experiments  by  Kronig  and  Menge  show  that 
bacteria  when  introduced  into  the  vagina  disappear  in  a  relatively 
short  time.  Irrigation  of  the  vagina  with  water  or  with  antiseptics 
retards  the  time  of  their  disappearance. 

The  body  of  the  healthy  uterus  is  ordinarily  free  from  micro- 
organisms. Stroganoff  found  the  bacteria  of  the  vagina  extending 
up  to  the  mucous  surface  of  the  cervix,  but  not  penetrating  it,  and 
experimentally  proved  the  mucus  an  unfavorable  medium. 

Powerful  as  are  the  normal  defences  against  bacterial  invasion, 
they  may,  however,  be  overthrown  under  conditions  very  imper- 
fectly understood.  The  more  important  bacteria  found  in  puerperal 
infections  are  the  streptococcus  and  staphylococcus,  Bacillus  coli 
communis,  and  Bacillus  aerogenes  capsulatus  (Plate  II). 

THE  BACTERIAL  EXCITANT  AND  HOST. 

Among  the  micro-organisms  gaining  entrance  into  the  body 
there  are  some  which  may  under  suitable  conditions  induce  phe- 
nomena by  which   disease   is  characterized.     These  are  the  ones 


24     INFECTION  CONSIDERED  IN  ITS  SURGICAL  RELATIONS 

which  induce  infectious  diseases,  and  which  we  habitually  refer  to 
as  being  pathogenic  bacteria.  The  term  "pathogenic"  is,  however, 
a  relative  one — a  fact  which  should  be  held  clearly  in  mind  for 
the  reason  that  an  organism  quite  harmless  to  one  animal  may 
be  capable  of  inducing  disease  in  another,  and  for  the  additional 
reason  that  an  organism  which  under  ordinary  conditions  is  harmless 
may,  under  special  conditions,  give  rise  to  definite  lesions. 

It  is  evident  from  what  has  been  said  that  infectious  disease 
cannot  occur  without  the  presence  in  the  body  of  living  micro- 
organisms. But,  on  the  other  hand,  the  mere  entrance  of  bacteria 
into  the  tissues  is  not  sufficient  to  constitute  infection,  for  it  has 
been  seen  that  many  bacteria  are  harmless,  and  that  the  body 
possesses  important  safeguards  whereby  bacteria  are  destroyed  or 
their  effects  neutralized.  Whether  the  micro-organisms  possess  patho- 
genic activity  or  not  will  depend  largely  upon  the  host,  and  also 
upon  their  own  variable  nature  and  qualities.  This  relationship 
of  host  and  bacterial  excitant  has  been  stated  so  admirably  by 
Prudden  that  one  can  do  no  better  than  quote  the  following : 

"In  the  study  of  the  infectious  diseases  it  is  especially  important 
to  bear  in  mind  that  the  abnormal  processes  through  which  the 
disturbances  incited  by  micro-organisms  are  manifested  are  processes 
of  the  body  cells,  and  not  processes  of  the  micro-organisms.  The 
micro-organisms  do,  indeed,  incite  the  train  of  phenomena  by 
which  the  disease  is  manifested,  and  the  nature  or  'species'  of  the 
micro-organism  may  largely  influence  the  character  of  the  phe- 
nomena; but  the  stored-up  energy  which  is  released  in  this  manifesta- 
tion is  body-cell  energy,  and  not  that  of  microbic  metabolism.  The 
microbes  are  excitants  of  disease,  but  the  disease  is  a  performance  of 
the  body  cells.  If  these  obvious  considerations  be  held  in  view, 
it  will  be  convenient  in  considering  certain  of  the  infectious  diseases 
to  use  the  familiar  and  much-abused  term  'specific'  as  indicative 
of  those  phases  of  abnormal  body-cell  performance  which  are  apt  to 
occur  in  characteristic  ways  in  response  to  special  forms  of  microbic 
stimulus.  Thus  the  poisonous  substances  which  the  tubercle 
bacillus  builds  up  out  of  the  organic  material  upon  which  it  feeds 
are  in  part  such  as  exert  a  peculiar  influence  upon  connective-tissue 
cells,  leading  to  their  proliferation  and  the  temporary  formation 
of  new  tissue — the  tubercle.  This,  together  with  associated  action 
of  the  same  or  other  metabolic  products  of  the  living  bacillus,  forms 
a  group  of  lesions  and  disturbances  which  is  characteristic  of  the 
action  of  the  tubercle  bacillus  in  the  body.  In  this  sense  tuberculosis 
is  a  'specific'  disease.  On  the  other  hand,  the  poisons  elaborated  by 
the  tubercle  bacillus  may  incite  responses  on  the  part  of  the  body 
cells  which  are  practically  identical  with  those  which  many  other 
toxic  substances,  both  of  bacterial  and  of  other  origin,  induce — 
fever,  degeneration,  etc.  These  manifestations  of  the  action  of  the 
tubercle  bacillus  upon  the  living  body  cells  are  not  'specific' 


THE  BACTERIAL  EXCITANT  AND  HOST  25 

The  Bacterial  Excitant. — The  reaction  of  the  body  cells  in  infection 
bears  a  more  or  less  constant  relation  to  the  virulence  of  the  infect- 
ing micro-organism  and  to  the  number  of  bacteria  gaining  entrance 
into  the  tissues.  The  virulence  varies  considerably  under  different 
conditions,  and  according  as  these  variations  are  small  or  great 
different  phenomena  will  develop  within  the  body.  The  character 
of  the  processes  induced  will  necessarily  vary  according  to  the 
virulence  of  the  infecting  bacterium;  and  this  largely  depends 
upon  its  environment,  which  may  not  only  modify  the  morphologic: 
character  of  the  organism  but  also  may  change  its  physiologic 
activities.  For  example,  Bacillus  coli  communis,  as  found  normally 
in  the  intestines,  is  of  very  low  virulence,  and  is  not  capable  of  inciting 
pathologic  processes;  but  so  soon  as  its  physiologic  activities  are 
modified  by  changes  in  its  environment  its  virulence  is  apt  to  be 
very  much  increased.  This  influence  of  environment  is  also  well 
shown  by  the  modifications  which  may  occur  in  the  vital  activity 
of  an  organism  when  it  finds  its  habitat  in  new  and  unnatural  hosts. 

Bacteria  which  enter  the  body  associated  with  their  toxic  products 
are  much  better  able  to  induce  infection  than  when  they  enter 
deprived  of  their  products.  These  toxic  substances,  by  damaging 
at  the  outset  cells  and  fluids  which  protect  the  body  from  infection, 
enable  the  invader  to  gain  a  foothold  which  it  otherwise  might 
not  have  obtained.  A  similar  effect  is  probably  produced  by  the 
hypothetical  substances  called  aggressins  by  Bail,  which  occur  in 
inflammatory  exudates. 

As  a  rule,  bacteria  lose  their  virulence  with  greater  or  less  readiness 
when  cultivated  in  artificial  media.  On  the  other  hand,  successive 
passages  of  a  pathogenic  organism  through  highly  susceptible 
animals  exalt  its  virulence.  Thus  a  streptococcus  of  attenuated 
virulence  may  be  exalted  a  hundredfold  or  more  by  successive 
inoculation  into  rabbits. 

Differences  in  the  virulence  of  bacteria  often  suffice  to  explain 
differences  in  the  clinical  and  morphologic  types  of  disease.  It  is 
well  known  that  under  some  conditions  an  organism  of  low  virulence 
will  incite  rather  mild  reactions  of  the  body  cells;  whereas,  under 
other  conditions,  when  the  virulence  of  the  same  organism  is  exalted, 
the  effects  are  more  marked  both  in  severity  and  extent  of  the  lesions. 
At  the  same  time,  with  the  most  virulent  organisms  the  local  lesion 
may  be  insignificant  and  the  general  disturbance  extreme. 

The  number  of  micro-organisms  which  gain  entrance  into  the 
body  is  also  a  factor  which  modifies  the  character  and  extent  of 
the  cellular  reactions.  Within  certain  limitations  the  healthy 
body  may  dispose  without  apparent  injury  of  a  certain  number  of 
bacteria  of  given  virulence;  but  when  the  same  organism  is  introduced 
in  large  quantities  infection  follows.  In  highly  susceptible  animals 
probably  so  small  a  number  as  one  or  two  anthrax  bacilli  may  incite 
disease.     Usually,  however,  much  larger  numbers  are  necessary  for 


26     INFECTION  CONSIDERED  IN  ITS  SURGICAL   RELATIONS 

the  development  of  an  infection.  The  question  of  dosage  is  largely 
one  of  individual  and  racial  susceptibility  on  the  one  hand,  and  of 
virulence  of  the  micro-organisms  on  the  other  hand.  The  kind  of 
infection  produced  by  some  bacteria  varies  with  the  dose.  Thus 
it  often  happens  that  the  introduction  of  a  very  small  number  will 
produce  only  a  local  infection,  whereas  larger  numbers  may  induce 
septicemia.  Further,  according  to  the  portal  of  entry,  we  find 
variations  in  the  character  of  the.  infectious  process.  Thus,  a  given 
dose  of  bacteria  which  when  injected  into  the  subcutaneous  tissues 
of  an  animal  may  prove  quite  harmless,  may  induce,  when  the 
same  dose  is  introduced  intravenously  or  into  the  peritoneal  cavity, 
well-marked  abnormal  cellular  reactions. 

The  study  of  the  influences  which  other  associated  organisms 
may  bring  into  play  in  the  development  of  infection  is  an  exceedingly 
interesting  one.  Mixed  infections  are  common  in  the  human  being, 
especially  in  suppurating  wounds,  in  which  it  is  usual  to  find  more 
than  one  bacterial  species.  Sometimes  the  association  of  one 
species  may  be  without  influence  upon  the  properties  of  another, 
or  it  may  enhance  or  lower  the  virulence  of  one  or  the  other.  Bacteria 
exert  their  influences  on  each  other  largely  through  their  chemical 
products,  and  it  is  often  possible  to  bring  about  modifications  of 
character  by  exposing  one  species  to  the  action  of  the  chemical 
products  of  another.  Such  a  process  is  exemplified  by  the  action 
of  the  Bacillus  lactis  on  the  bacteria  of  intestinal  putrefaction — 
use  of  which  is  made  in  the  treatment  of  intestinal  auto-intoxication. 
Sometimes  concurrent  inoculation  of  two  different  bacterial  species 
inhibits  the  influence  of  one  or  both.  Thus,  simultaneous  inoculation 
of  Bacillus  pyocyaneus  and  Bacillus  anthracis  into  a  susceptible 
animal  is  often  without  pathogenic  effect.  More  often,  however, 
the  concurrent  inoculation  of  two  species  rather  increases  the  danger 
from  one  or  both,  although  sometimes  a  bacterium  of  attenuated 
virulence  may  become  augmented  in  virulence  by  the  inoculation 
of  another  species  which  need  not  necessarily  be  pathogenic  itself. 
Thus  the  pathogenic  effects  of  the  tetanus  bacillus  arc  much  enhanced 
when  it  is  associated  with  pyogenic  bacteria.  It  sometimes  happens 
that  infection  with  one  species  paves  the  way  for  infection  with 
another. 

The  Host. — It  is,  of  course,  well  known  that  certain  bacteria 
will  induce  infections  only  in  separate  species  of  animals,  proving 
absolutely  innocuous  for  other  species.  Thus,  while  the  anthrax 
bacillus  usually  induces  lesions  with  the  greatest  readiness  in  many 
animals,  others,  like  the  white  rat,  are  ordinarily  insusceptible  to 
inoculation  with  these  bacilli  unless  very  large  amounts  be  given 
or  special  factors  be  brought  into  play.  Furthermore,  some  diseases 
are  especially  peculiar  to  man,  such  as  typhoid  fever,  leprosy, 
scarlet  fever,  measles,  etc.,  these  diseases  never  occurring  naturally 
in  animals. 


ACTION  OF  BACTERIA  AS  I)  THEIR  PRODUCTS  IN  THE  BODY     27 

Racial  predisposition  may  be  inherited  or  acquired,  or  general  or 

local.  Negroes  arc  generally  insusceptible  to  yellow  fever,  whereas 
other  human  beings  are  quite  susceptible  to  the  pathogenic  agents 
of  this  disease. 

The  influence  of  age  is  so  well  known  that  investigators  commonly 
make  use  of  this  knowledge  in  their  experimental  work.  As  a 
predisposing  factor  to  infection  this  is  well  illustrated  by  the  curve 
of  frequency  of  infections  diseases  in  man,  the  maximum  point 
occurring  in  children.  Numerous  other  conditions  affecting  the 
normal  physiologic  integrity  of  the  body  also  favor  the  development 
of  infectious  disease.  For  example,  the  influence  of  fatigue,  starva- 
tion, cold  and  heat,  and  loss  of  blood  has  been  studied  particularly 
from  an  experimental  point  of  view,  the  results  conclusively  proving 
that  a  marked  susceptibility  to  infection  is  developed  when  any  of 
these  factors  is  brought  into  play. 

Other  factors  have  also  been  investigated,  such  as  the  action  of 
chemical  substances  and  unsuitable  diet,  the  latter  especially  by 
Hankin,  who  fed  refractory  rats  on  sour  milk  and  bread.  Such 
treatment  made  the  animals  extremely  susceptible  to  anthrax 
infection. 

The  local  predisposition  may  be  limited  to  one  or  more  of  the 
portals  of  entry,  or  it  may  exist  at  some  point  within  the  body, 
constituting  a  so-called  locus  minoris  resistentiae.  The  character 
of  the  tissue  infected,  the  presence  of  local  anemia  or  passive  hyper- 
emia, the  withdrawal  of  nerve  impulses  from  a  point,  the  rapidity 
of  absorption,  the  presence  of  foreign  bodies,  are  also  modifying 
factors  in  the  susceptibility  to  infection.  Wounds  through  poorly 
vascularized  tissues  generally  offer  but  slight  resistance  to  bacterial 
invasion.  The  presence  of  edema  in  the  tissue  likewise  favors 
infection. 

Contrary  to  the  general  belief,  suppurating  surfaces  offer  con- 
siderable resistance  to  the  entrance  of  bacteria  into  the  body,  for 
pus  possesses  distinct  bactericidal  power,  partly  from  the  cells  and 
partly  from  the  fluid  portion.  Thus  the  danger  of  bacterial  absorp- 
tion from  suppurating  surfaces  is  much  less  than  from  fresh  wounds. 
The  existence  of  suppuration,  however,  lowers  the  general  resistance 
of  the  individual. 

Among  the  local  conditions  favoring  the  growth,  in  wounds,  of 
bacteria  which  might  otherwise  be  disposed  of  by  the  tissues  or 
animal  fluids,  may  be  mentioned  strangulation  of  masses  of  tissue 
by  ligature,  the  presence  of  foreign  bodies,  interference  with  the 
circulation  from  undue  pressure  and  tension. 

ACTION  OF  BACTERIA  AND  THEIR  PRODUCTS   IN   THE  BODY. 

Micro-organisms  induce  their  effects  in  several  ways,  but  chiefly 
by  their  presence  in  the  tissues,  and  by  the  development  of  their 


28     INFECTION  CONSIDERED  IN  ITS  SURGICAL  RELATIONS 

poisonous  products,  which  either  .affect  the  physiologic  activity  of 
the  cell  or  kill  the  cell  outright.  These  poisonous  products  act  in 
varying  degree,  generally  or  locally,  according  to  the  nature  and 
quantity  of  the  product  formed.  Such  toxic  substances  become 
diffused  through  the  system,  and  the  clinical  manifestation  of  their 
effects  is  shown  by  the  occurrence  of  fever,  disturbances  in  the 
functions  of  the  respiratory  and  nervous  systems.  In  some  cases 
changes  are  found  locally  in  the  tissues  directly  involved.  The 
general  effects  of  bacterial  poisons  may  be  so  slight  as  to  be  regarded 
as  of  little  importance,  as  in  the  case  of  a  local  inflammation;  or 
they  may  be  very  intense,  as  in  tetanus  and  diphtheria.  In  diseases 
like  tetanus  and  diphtheria  it  is  usually  only  in  the  local  lesion  that 
the  bacilli  are  found;  and  the  profound  systemic  intoxication  is  due 
to  absorption  of  the  highly  toxic  products  from  the  local  lesion. 

Whenever  there  is  a  widespread  distribution  of  pathogenic  bacteria 
in  the  blood  the  condition  is  designated  septicemia;  and  if  associated 
with  multiple  foci  of  pus-formation,  the  term  pyemia  is  applied. 
The  body,  which  is  already  the  seat  of  infectious  disease,  is  much 
more  susceptible  to  invasion  by  other  bacteria;  thus,  mixed  or 
concurrent  infections  are  often  present.  Individuals  the  victims  of 
long-standing  chronic  diseases,  such  as  those  of  the  heart,  lungs, 
kidneys,  and  liver,  often  succumb  to  infectious  diseases  of  one  kind 
or  another.  The  term  terminal  infection  has  been  applied  by  Osier 
to  these  infectious  diseases. 

IMMUNITY. 

Immunity  is  characterized  by  resistance  to  infection  or  its  effects. 
The  absence  or  loss  of  this  capacity  is  known  as  susceptibility. 
Immunity  from  an  infectious  disease  may  be  hereditary  or  it  may 
be  acquired,  either  by  an  attack  of  the  disease  from  which  the 
individual  has  recovered — natural  immunization — or  by  the  intro- 
duction into  the  body  of  something  which  diminishes  susceptibility — 
artificial  immunization. 

Many  of  the  infectious  diseases  confer  greater  or  lesser  immunity 
to  subsequent  attacks  of  the  same  disease,  although  there  are  excep- 
tions to  this  rule.  A  previous  attack  of  erysipelas  renders  one  more 
susceptible  to  subsequent  infection  with  the  streptococcus. 

From  the  study  of  infection  it  is  known  that  two  distinct  influences 
are  evidently  at  play  in  enabling  the  body  to  resist  infection.  It 
has  clearly  been  shown  that  the  destruction  of  bacteria  may  in 
part  be  brought  about  by  the  leukocytes  and  other  mesodermal 
cells,  which  when  thus  engaged  are  called  phagocytes.  In  the  body 
fluids  there  are  also  certain  albuminous  ingredients  which  have 
well-marked  bactericidal  properties. 

A  number  of  theories  have  been  advanced  to  explain  the  essential 
nature  of  immunity.     They  may  be  grouped  into  two  classes:  The 


IMMUNITY  29 

humoral,  which  attributes  immunity  to  extracellular  fluids  of  the 
body,  and  the  cellular,  which  assumes  that  the  direct  action  of  the 
body  cells  is  most  important. 

The  humoral  products  of  immunity,  which  are  best  known,  are 
antitoxins,  lysins,  opsonins,  precipitins,  and  agglutinins. 

Antitoxins  result  after  the  introduction  into  the  body  of  toxins 
under  suitable  conditions,  and  are  protective  and  curative  because 
they  unite  with  toxin  of  the  kind  which  has  called  it  forth  and 
prevent  it  from  causing  disease  by  union  of  the  body  cells  with 
toxin. 

Lysins  result  from  the  introduction  into  the  body  of  bacteria 
and  other  cellular  bodies,  under  suitable  conditions,  and  act  by 
dissolving  or  destroying  the  cellular  bodies  of  the  type  which  called 
forth  their  production. 

Opsonins  are  substances  in  the  serum  which  result  after  the 
introduction  into  the  body  of  bacteria  and  some  other  cellular 
bodies  under  suitable  conditions,  and  act  by  forming  a  union  with 
these  cellular  bodies  in  such  a  way  that  they  may  be  more  readily 
engulfed  by  phagocytic  leukocytes. 

Precipitins  are  substances  in  the  blood  serum  which  result  from 
the  injection  into  the  body  of  various  protein  substances  of  animal, 
vegetable,  or  bacterial  nature  having  the  power  of  forming  a  pre- 
cipitation when  mingled  with  these  substances.  This  action  is 
more  or  less  specific  for  the  especial  form  of  substance. 

The  same  is  true  of  agglutinins,  which  under  similar  circumstances 
are  capable  of  drawing  together  into  clumps  bacteria  and  other 
cellular  bodies  which  have  been  introduced  into  the  serum  of  animals. 

While  precipitins  and  agglutinins  are  thought,  undoubtedly,  to 
have  a  place  in  the  protective  mechanism  of  the  body,  their  true 
role  is  not  yet  known. 

As  methods  of  determining  the  type  of  infection  which  the  body 
is  undergoing,  however,  these  phenomena — on  account  of  their 
specific  action — are  great  diagnostic  aids.  The  one  best  known 
at  the  present  time  is  the  agglutination  of  typhoid  bacilli  in  the 
presence  of  the  serum  of  typhoid  fever  patients,  known  as  the 
Widal  reaction. 

As  a  result  of  these  phenomena  the  following  various  serothera- 
peutic  measures  have  been  inaugurated  to  overcome  the  deleterious 
effects  of  bacterial  infection. 

Curative  injections  by  (a)  active  immunization  and  (6)  passive 
immunization. 

(a)  Active  immunity  is  secured  through  the  action  in  the  body 
of  bacteria  whose  virulence  has  been  reduced  but  not  rendered 
altogether  inert.  Common  examples  are  bacterial  suspensions, 
recently  designated  as  vaccines,  of  staphylococci,  streptococci, 
gonococci,  colon  bacilli,  and  other  organisms. 

The  use  of  these  substances  has  been  encouraged  through  the 


30     INFECTION  CONSIDERED  IN  ITS  SURGICAL  RELATIONS 

researches  of  Wright,  who  recommends  the  use  of  the  opsonic  index 
to  regulate  the  size  and  intervals  of  their  dosage. 

Bacterial  vaccines  are  prepared  from  cultures  of  the  organisms 
causing  the  infection,  grown  on  agar.  A  suspension  is  made  of 
the  bacteria  in  normal  salt  solution,  and  this  is  then  standardized 
by  determining  the  number  of  bacteria  per  cubic  centimeter  of  fluid. 
After  sterilization  by  exposure  to  a  temperature  of  from  65?  to 
75°  C'  for  half  an  hour  and  the  addition  of  0.5  per  cent,  lysol,  this 
material  is  ready  for  inoculation. 

Tuberculin — especially  Koch's  new  tuberculin,  known  as  tuber- 
culin R — is  a  substance  belonging  to  this  class  of  immunizing  agents. 
Up  to  the  present  time  this  form  of  immunization  has  been  most 
successful  in  cases  of  localized  infection. 

(6)  Passive  immunity  is  secured  by  the  direct  mingling  of  the 
body  fluids  from  an  individual  already  immunized  with  those  of 
the  individual  to  be  protected.  Such  fluids  are  the  antitoxic  sera — 
represented  by  diphtheria  and  tetanus  antitoxin  and  others — and 
antibacterial  sera,  to  which  group  belong  the  sera  of  typhoid,  cholera, 
plague,  dysentery,  etc. 

These  methods  may  be  applied  not  only  for  curative  purposes 
but  also  to  prevent  the  effects  of  future  infections.  Protective 
passive  immunization  may  thus  be  obtained  for  comparatively 
short  periods  of  time  by  the  use  of  diphtheria  and  tetanus  antitoxins 
where  infection  by  the  corresponding  organism  is  threatened. 

Of  the  agencies  producing  protective  active  immunization,  the 
most  familiar  are  the  vaccine  of  Jenner,  producing  immunity  to 
smallpox,  and  the  antirabies  vaccine  of  Pasteur.  In  both  of  these 
cases,  as  well  as  in  some  successful  experiments  in  tuberculosis 
immunity,  immunization  is  secured  through  the  injection  of  living 
attenuated  organisms.  The  use  of  dead  organisms  as  vaccines  for 
the  production  of  active  immunity  has  recently  met  with  a  certain 
degree  of  success  in  protection  against  infection  of  typhoid  fever, 
plague,  and  some  of  the  pyogenic  organisms.  The  protection 
afforded  by  active  immunization  is  generally  of  longer  duration 
than  that  afforded  by  passive  immunization. 

It  is  to  Metchnikoff  and  his  pupils  that  we  owe  most  of  the  facts 
upon  which  the  cellular  theories  of  immunity  are  based.  Immunity, 
it  is  asserted  by  those  who  take  this  view  of  immunity,  is  dependent 
upon  the  activity  of  living  cells,  the  germicidal  action  of  the  body 
fluids  being  due  to  secretions  from  the  leukocytes  and  other  cells. 
(See  Phagocytosis,  under  Inflammation.)  It  is  probable  that 
the  body  fluids  and  body  cells  both  play  an  important  role  in  the 
development  of  immunity. 


CHAPTER  II. 

INFLAMMATION. 

Introduction. — With  a  fuller  appreciation  of  the  structure  and 
physiologic  traits  of  the  tissues,  chiefly  based  on  studies  in  biology 
and  comparative  pathology,  the  original  significance  given  to  the 
process  of  inflammation  has  been  much  changed  within  recent 
years.  Originally  the  conception  of  inflammation  was  a  comparative 
simple  one,  based  chiefly  on  certain  clinical  manifestations — redness, 
heat,  swelling,  pain,  and  impaired  function;  but  now  it  is  regarded 
as  a  far  more  complex  local  process,  in  which  circulatory  disturbances 
and  retrogressive  and  progressive  changes  are  associated  in  varying 
degrees.  These  changes  are  induced  by  some  form  of  injury.  While 
the  external  manifestations  of  the  process  may  vary  considerably, 
it  has  been  shown  that  in  each  case  the  fundamental  changes  are 
essentially  the  same  whatever  the  exciting  cause.  Thus  inflamma- 
tion has  been  defined  by  Adami  as  "the  local  adaptive  changes 
resulting  from  actual  or  referred  injury." 

INFLAMMATION. 

Cause. — Although  the  varieties  of  inflammation  are  dependent 
upon  the  character  of  the  cause,  they  may  be  grouped,  according 
to  their  intensity  and  duration,  into  the  acute  and  chronic  forms. 

In  either  form  the  active  or  exciting  cause  may  have  been  physical, 
chemical  or  thermal  change.  Inasmuch  as  the  bacteria  and  other 
microorganisms  produce  inflammation  in  their  metabolism  they  do 
so  by  chemical  changes. 

While  any  one  of  these  agencies  may,  in  itself,  be  sufficient  to 
incite  inflammation,  in  some  instances  they  are  only  able  to  produce 
this  result  through  the  operation  of  some  predisposing  cause. 

Acute  Inflammation. — Symptoms. — Local. — The  cardinal  signs  of 
inflammation  have  long  been  recognized  as  heat,  redness,  swelling, 
and  pain,  and  to  these  may  be  added  interference  with  function  in 
the  inflamed  part  and  general  constitutional  disturbance.  While 
inflammation  may  exist  in  the  absence  of  some  of  these  signs,  and 
while  some  of  them  may  occur  with  conditions  other  than  inflamma- 
tion, the  coexistence  of  all,  or  even  of  a  majority  of  them,  is  usually 
sufficient  to  establish  the  diagnosis  of  inflammation.  The  redness 
is  due  to  arterial  and  especially  to  venous  and  capillar}'  hyperemia; 
the  swelling,  on  the  other  hand,  is  due  partly  to  hyperemia,  serous 


32  INFLAMMATION 

exudation,  and  leukocytic  emigration.  The  pain  is  due  possibly 
to  increase  of  tissue  tension  irritating  the  nerve  ends  or  possibly 
to  the  direct  actions  of  the  inflammatory  irritants  upon  the  nerve 
ends.  Although  the  temperature  of  the  involved  part  may  be 
elevated  beyond  the  normal,  it  never  exceeds  that  of  the  interior 
of  the  body.  Disturbances  or  loss  of  function  depend  on  the  struct- 
ural and  functional  alterations  which  occur  in  the  tissue  affected. 

General  Symptoms. — These  may  be  absent  in  inflammations  of  a 
limited  and  moderate  nature;  but  when  the  inflammation  is  extensive 
and  severe,  fever  is  ordinarily  present.  It  is  induced  by  the  absorp- 
tion of  substances  from  the  local  area  of  inflammation.  There 
may  be  leukocytosis,  polymorphonuclear  in  type,  with  the  inflam- 
matory processes  due  to  certain  bacterial  invasions.  Such  inflamma- 
tory processes  are  the  result  of  invasions  by  the  so-called  pyogenic 
organisms. 

Clinically,  all  cases  with  fever  are  attended  with  certain  symp- 
toms in  common,  due  partly  to  increased  tissue  changes,  partly  to 
increased  heat  of  the  body,  and  in  part  to  functional  disturbances 
of  certain  organs.  There  may  be  malaise,  sleeplessness,  thirst, 
loss  of  appetite,  mental  disturbance,  increased  frequency  of  pulse 
and  respiration,  lessened  amount  of  urine,  etc.  If  the  absorption 
of  poisons  is  excessive,  or  a  vital  organ  is  involved,  death  may 
result,  or  all  symptoms  may  subside  and  the  process  may  terminate 
in  resolution,  or  may  continue  as  a  chronic  condition. 

In  acute  inflammation  the  character  of  the  minute  tissue  changes 
depends  upon  the  vascularity  or  non-vascularity  of  the  tissues.  In 
non-vascular  tissue  the  process  of  inflammation  is  eventually  similar 
to  that  in  vascular  tissues.  In  the  non-vascular  cornea,  tendons,  and 
heart  valves,  vessels  rapidly  develop.  In  this  way  a  non-vascular 
tissue  becomes  vascular.  With  the  appearance  of  the  vessels 
the  tissues  become  permeated  with  wandering  leukocytes.  These 
leukocytes  emigrate  from  the  vessels  and  adjacent  tissue  zones  to 
the  inflammatory  focus  through  so-called  positive  chemota.ris. 
This  chemotaxis  is  exerted  through  tissue  debris  and  particularly 
pyogenic  organisms. 

Many  of  the  leukocytes  may  take  up  micro-organisms,  and  by 
the  action  of  intracellular  ferments  bring  about  more  or  less  com- 
plete digestion  of  the  ingested  bacteria.  This  phenomenon  is 
known  as  phagocytosis.  While  usually  resulting  in  the  destruction 
of  the  ingested  bacteria,  these  are  not  always  killed;  on  the  con- 
trary, under  some  circumstances  the  ingested  bacteria  and  their 
products  may  destroy  the  phagocytes. 

The  digestive  action  of  leukocytes  on  bacteria  may  not  be  con- 
fined to  bacteria  within  their  bodies,  for  after  their  disintegration 
ferments  may  be  released  and  imparted  to  the  exudate  or  serum 
which  have  a  bactericidal  action.  To  such  substances  the  term 
alexins  has  been  applied. 


INFLAMMATION 


33 


Tn  the  earliest  stages  of  inflammation  there  is  arterial  dilatation, 
and  at  the  same  time  an  increase  in  the  rapidity  of  flow  of  blood, 
which  is  of  short  duration.  This  is  followed  by  a  dilatation  of 
the  veins  and  capillaries,  with  a  slowing  of  the  blood  current.  The 
leukocytes  now  have  a  decided  tendency  to  accumulate  in  the 
outer  portion  of  the  veins  and  capillaries,  and  to  adhere  to  the 
vessel  walls.  This  is  followed  by  emigration  of  the  leukocytes 
through  the  vessel  walls.  The  slowing  of  the  blood  current  is 
progressive,  and  in  some  vessels  complete  stasis  occurs.     Red  cells 


Fig.  1. — Mesentery  of  frog  in  the  early  stage  of  an  acute  inflammation.  All  of  the 
vessels  are  dilated.  The  leukocytes  are  more  numerous;  they  have  collected  along  the 
walls  of  the  vessels,  and  in  several  places  are  passing  through;  at  d  diapedesis  of  the  red 
corpuscles  is  shown,  and  at  e  emigration  of  leukocytes.  There  are  large  numbers  of 
leukocytes  in  the  connective  tissue.     (Dennis.) 


may  escape  into  the  tissues  either  by  diapedesis  or  rhexis.  Plasma 
also  escapes,  the  fibrinogen  of  which  coming  in  contact  with  the 
ferments  of  disintegrating  leukocytes,  forms  fibrin  (Figs.  1  and  2). 

If  now  the  cause  of  the  inflammation  ceases  to  act,  and  the  vitality 
of  the  tissues  has  not  been  too  much  lowered  to  permit  of  their  recov- 
ery, the  stasis  ceases,  the  emigration  of  leukocytes  discontinues,  and 
those  that  have  already  escaped  wander  back  into  the  bloodvessels 
or  lymphatics,  or  disintegrate — the  dead  cells  being  dissolved  by 
cellular  ferments — and  the  part  is  left  apparently  uninjured.  This  is 
3 


34 


INFLAMMATION 


called  resolution.  This  inflammatory  process  in  the  tissues,  especially 
if  due  to  bacterial  invasion,  clinically  is  known  as  a  cellulitis. 

The  tissue  damage  by  a  suppurative  process  may  be  replaced  by 
thickened  or  indurated  tissue,  giving  rise  to  a  connective-tissue  fibrosis 
— often  resulting  in  cicatrization — or  all  the  tissues  in  the  inflamed 
area  may  lose  their  vitality  and  die  en  masse  {gangrene). 

Chronic  Inflammation. — While  chronic  inflammation  may  be  the 
immediate  result  of  the  specific  infectious  agencies  of  such  diseases  as 
tuberculosis  and  syphilis,  it  may  result  secondarily  to  an  acute  process 
from  other  causes  where  the  exciting  factors  continue  in  operation. 


- '     -V.  ';v^$&v  ''*•'&$&*&££ 


Fig.  2. — Acute  inflammation  of  an  appendix,  showing  dilated  lymph  vessel  and 
leukocytic  migration. 


The  causes  of  chronic  inflammation  are  similar  in  kind  to  those  of 
the  acute  processes,  but  act  with  less  intensity  and  for  longer  periods 
of  time.  The  local  symptom — redness,  pain,  and  heat — may  be  very 
slight  or  entirely  absent.     Swelling  is  frequently  a  marked  sign. 

The  minute  tissue  changes  in  the  early  stages  resemble  those  of  the 
acute  form,  with  greater  sluggishness  of  the  blood  supply  and  pro- 
liferation of  the  fixed  tissue  elements.  This  may  result  in  the  collection 
in  the  adjacent  tissue  of  numerous  small  round  cells.  In  other  cases, 
as  in  syphilis,  actinomycosis,  or  tuberculosis,  the  local  irritation  pro- 
duced by  the  specific  organism  gives  rise  to  circumscribed  areas  of 
round-cell  infiltration,  which  have  a  strong  tendency  toward  necrosis, 
caseation,  or  calcification.    These  lesions  are  spoken  of  as  the  infect  ire 


PLATE    II 


Section  through  wall  of  abscess,  showing 
Staphylococcus  pyogenes, aureus.  (Baum- 
garten.) 


Cover-glass  preparation  of 
pericardial  exudate,  showing 
Bacillus  pyocyaneus  stained 
blue  and  the  tubercle  bacillus 
stained  red.     (Ernst.) 


T 


MM  i 


•;. 


«  s 


{ 


Streptococcus  pyogenes.       Streptococcus  erysipelatis. 
(Prudden.) 


ft> 


I 


^A 


Micrococcus    gonorrhea   or 
gonoeoecus.     (Abbott.) 


Micrococcus    lanceolatus 
(Abbott.) 


Some  Forms  of  Bacteria   Giving    Rise  to  Surgical  Infections. 


SUPPURATIOX  35 

granvlomata.  Like  acute  inflammation,  the  chronic  may  terminate  in 
resolution,  suppuration,  or  ulceration;  but  the  fibrous  and  necrotic 
changes  just  described  are  the  terminal  results  most  frequently  seen. 


SUPPURATION. 

Suppuration  is  produced  by  the  action  on  the  tissues  of  the  body 
of  certain  organisms  known  as  the  pyogenic  bacteria.  While  some  of 
these,  as  the  staphylococci,  streptococci,  the  pneumococcal,  gono- 
coccus,  Bacillus  coli  communis  and  Bacillus  pyocyaneus  nearly  always 
produce  pus,  others  are  capable  of  producing  pus  only  at  times. 

To  this  group  belong  the  typhoid,  proteus,  tubercle,  anthrax,  and 
glanders  bacilli,  and  the  bacillus  of  malignant  edema.     (Plate  II.) 

Pus,  caused  by  these  organisms  as  a  class,  is  a  yellowish  creamy 
substance  with  a  faint  odor,  having  an  alkaline  reaction  and  a  specific- 
gravity  of  about  1030.  It  is  composed  of  a  solid  and  a  liquid,  the 
former  consisting  of  leukocytes,  some  of  which  may  still  retain  ameboid 
movements,  most  of  which,  however,  are  undergoing  degeneration  and 
disintegration.  In  addition  to  these  may  be  found  dead  tissue  cells, 
red  blood  corpuscles,  fibrin,  micro-organisms,  etc.  The  liquid  part 
resembles  modified  plasma,  which  does  not  clot  on  standing,  but  which 
may  be  coagulated  on  boiling. 

Certain  variations  in  the  appearance  of  pus  are  dependent  upon  the 
character  of  the  organisms  calling  it  forth. 

For  example,  while  the  pus  in  staphylococcus  infection  is  grayish 
white,  moderately  thick,  with  a  somewhat  sour  odor,  that  of  the 
Bacillus  coli  communis  is  thick,  brownish,  with  fetid  odor;  or  thin, 
grayish  white,  with  thicker  masses. 

Pus  from  streptococcus  infection  is  usually  thin,  white,  often  blood- 
tinged,  with  shreds  of  tissue,  while  that  from  the  Bacillus  pyocyaneus 
is  distinctly  green  or  blue. 

Pneumococcus  pus  is  usually  thin,  watery,  and  greenish,  while 
tubercle  bacillus  pus  is  usually  thick,  curdy,  paste-like,  or  thin  and 
greenish,  containing  cheesy  lumps. 

A  suppurative  process  may  occur  in  a  circumscribed  area,  forming 
a  local  abscess,  or  it  may  infiltrate  the  tissues,  forming  a  diffuse 
cellulitis. 

Acute  Abscess. — The  minute  tissue  changes,  occurring  in  the 
early  stages  of  abscess  formation,  have  already  been  described  under 
inflammation.  If  the  inciting  organism  remains  active,  the  exuded 
leukocytes  gather  about  the  focus  in  large  number.-,  with  the  other 
products  of  inflammation,  and  as  a  result  of  the  action  of  the  bacterial 
poisons,  these  cells,  as  well  as  endothelial  and  connective-tissue  cells, 
die.  Through  the  action  of  cellular  and  bacterial  ferments,  leukopro- 
teoses,  the  tissues  are  digested  into  a  semifluid  mass.  This  mass  or 
"slough"  is  frequently  found  lying  free  in  an  abscess  cavity;  at  other 


36 


INFLAMMATION 


times  the  necrotic  mass  is  completely  liquefied,  resulting  in  a  collection 
of  homogeneous  pus. 

About  this  central  focus  is  an  inflammatory  zone  of  tissue,  infil- 
trated by  leukocytes  and  other  products  of  inflammation,  in  which 
the  capillaries  are  dilated. 

As  the  process  extends  the  central  area  of  necrosis  becomes  larger. 
As  the  pressure  at  this  point  is  considerable,  the  process  extends  in 
the  direction  in  which  the  tissue  structure  is  digested  more  rapidly 
by  the  proteolytic  ferments,  along  the  line  of  least  resistance,  until  it 
points  upon  a  free  surface  or  in  some  body  cavity.  In  the  course  of 
this  advance  the  pus  may  burrow  for  some  distance  between  fascial 
planes. 


./t-~- 


-**%$&** 


Fig.  3. — Recent  granulation.     Duration  48  hours. 

After  the  evacuation  of  pus,  bacteria,  and  other  irritants  from  the 
abscess  cavity,  healing  may  occur.  The  obliteration  of  the  defect  in 
the  tissues  left  by  the  abscess  cavity  is  brought  about  partly  through 
the  proliferation  of  so-called  "granulation  tissue,"  and  partly  by  the 
collapse  of  the  surrounding  tissues.  Granulation  tissue  consists  of 
newly  formed  connective  tissue  rich  in  blood  capillaries  (Figs.  3  and  4). 
With  the  tissue  defect  complete,  epithelium  from  the  adjacent  skin  or 
mucosa  is  found  to  have  covered  the  newly  formed  connective  tissue  or 
"scar."    The  entire  new  tissue  growth  is  called  the  "cicatrix." 

In  the  absence  of  repair  at  any  stage,  the  infection  may  travel 
along  the  lymphatics  supplying  the  part,  to  the  nearest  lymph  node, 
which  becomes  inflamed  and  enlarged.  The  process  may  stop  in  the 
first  or  second  of  a  chain  of  nodes,  or  the  infection  may  pass  into  the 
blood,  resulting  in  a  septicemia  or  pyemia,  which  may  prove  fatal. 
These  conditions  will  be  described  subsequently. 


SUPPURATION 


37 


Chronic  Abscess.  This  form  of  abscess  may  result  from  long 
duration  of  an  abscess,  originally  acute,  the  exciting  cause  of  which 
is  an  enfeebled  pyogenic  organism,  or  one  of  slight  virulence.  More 
frequently,  however,  a  chronic  abscess  is  of  slow  formation  from  the 
start,  and  due  to  infection  by  the  inciting  organism  of  tuberculosis, 
syphilis,  actinomycosis,  or  blastomycosis. 

The  pus  from  a  simple  chronic  abscess  may  be  thin  and  curdy, 
may  contain  shreds  of  necrotic  tissue,  but  often  differs  little  from 
ordinary  pus. 

Locally,  a  fluctuating  swelling  is  the  chief  sign,  often  unattended 
with  any  sign  of  inflammation.     Constitutional  symptoms  are  rare. 


•/"•'".  *V*W£Jl'  i 


.    ism  -^*m       s«  m     <**  »•      ■ 

4*£^3^'  *    ♦  •     .-V    •  - 


•  t 


*   *».*.»'• 


.** 


>    . 


Fig.  4. — Recent  granulation  tissue.     Duration  5  days. 

The  symptoms  and  treatment  of  chronic  abscess  will  be  considered 
in  subsequent  chapters. 

Sinus. — A  sinus  is  a  persistent  tract  which  communicates  with  an 
abscess  cavity. 

The  cause  is  usually  the  presence  of  a  foreign  body  in  the  original 
focus,  or  an  insufficient  outlet  from  an  abscess. 

Fistula. — Although  occasionally  the  result  of  a  wound,  ulceration, 
sloughing,  or  of  a  congenital  defect,  a  fistula  is  usually  due  to  the 
non-closure  of  an  abscess.  A  fistula  connects  some  hollow  viscus  or 
the  duct  of  a  secreting  gland  with  the  surface  of  the  body.  The 
fistulse  most  commonly  seen  occur  in  connection  with  the  gastro- 
intestinal tract,  the  urethra,  or  bladder. 


CHAPTER  III. 
ACUTE  INFECTIOUS  SURGICAL  DISEASES. 

ACUTE    GENERAL    SEPSIS. 

Septicemia,  Pyemia,  and  Septic  Intoxication. — Although  formerly 
considered  separate  diseases,  these  three  conditions  are  best  regarded 
simply  as  different  types  of  acute  general  sepsis.  Whenever  patho- 
genic bacteria  gain  access  to,  and  grow  in  the  systemic  circulation 
and  tissues,  the  condition  is  referred  to  as  septicemia.  If,  on  the  other 
hand,  such  generalized  infection  be  associated  with  the  development 
of  remote  foci  of  suppuration,  it  is  designated  pyemia.  It  has  been 
customary,  especially  among  surgeons,  to  limit  these  terms  to  infections 
with  the  pyogenic  micro-organisms.  The  term  septic  intoxication  is 
used  to  indicate  a  condition  due  to  the  absorption  of  toxins,  mainly  of 
bacterial  origin.  Sapremia  is  a  term  sometimes  employed  to  signify  a 
form  of  intoxication  due  to  absorption  of  the  poisons  of  putrefactive 
micro-organisms.  It  is  not  always  possible  to  distinguish  sharply 
between  infections  and  intoxications;  indeed,  the  manifestations  of 
infectious  disease  are  nearly  always  referable  to  bacterial  poisons. 

Some  infections  are  purely  local,  as  tetanus  and  diphtheria,  the 
most  important  lesions  and  symptoms  being  due  to  absorption  of 
toxic  substances  from  the  seat  of  inoculation.  The  so-called  intoxica- 
tions exhibit  themselves  by  febrile  manifestations,  nervous,  cardiac, 
and  respiratory  disturbances,  and  other  symptoms. 

The  septicemias  generally  may  be  traced  to  the  entrance  of  the 
bacteria  at  some  definite  portal;  but  sometimes  it  is  impossible  to 
determine  the  point  of  entrance — cryptogenetic  infections.  Many  of 
the  organisms  gain  access  to  the  blood  through  the  skin  or  mucous 
membranes  of  the  alimentary,  respiratory,  and  genito-urinary  tracts. 
Such  infections  may  follow  recent  or  old  injuries;  or  they  may  come 
on  in  the  course  of  various  diseases,  such  as  pneumonia,  erysipelas, 
typhoid  fever,  puerperal  fever,  etc. 

The  organisms  most  frequently  etiologically  related  to  the  develop- 
ment of  surgical  septicemias  are  Streptococcus  pyogenes,  Staphy- 
lococcus pyogenes  aureus,  Pneumococcus,  Bacillus  coli  communis, 
Gonococcus,  Bacillus  pyocyaneus,  Bacillus  aerogenes  capsulatus,  and 
Bacillus  anthracis.  More  than  one  bacterial  species  may  be  present 
in  the  blood.  The  bacteria  concerned  in  pyemia  are  essentially  the 
same  as  those  found  in  septicemia.  Why  they  should  in  one  instance 
induce  foci  of  suppuration  and  not  in  another,  it  is  not  always  possible 


ACUTE  GENERAL  SEPSIS  39 

to  state.  In  most  cases  there  is  some  primary  focus  of  infection,  either 
an  osteomyelitis,  an  otitis  media,  an  external  suppurating  wound,  a 
gonorrhea,  or  other  lesion  containing  pathogenic  bacteria.  Metastatic 
abscesses  usually  are  formed  by  fragments  of  infected  thrombi  which 
are  carried  into  the  circulation,  and  eventually  are  arrested  in  small 
vessels  and  thus  form  embolic  foci  of  suppuration.  The  abscesses  are 
generally  found  in  one  or  more  of  the  viscera,  as  the  kidneys,  lungs 
liver,  spleen,  or  heart.  When  the  focus  of  infection  is  within  the 
areas  supplied  by  the  portal  vein,  pylephlebitis  often  develops,  with 
multiple  abscesses  in  the  liver. 

At  autopsy  the  spleen  is  found  swollen  and  soft,  and  on  the  serous 
surfaces  minute  hemorrhages  are  frequent.  The  lungs  may  be  con- 
gested and  the  other  viscera  show  parenchymatous  degeneration. 
Embolism  and  thrombosis  with  infarction  are  not  uncommon. 

Symptoms. — In  all  cases  of  acute  general  sepsis  there  are  fever, 
prostration,  and  rapid  wasting.  In  the  intoxications  due  to  an  accessible 
septic  focus  there  is  often  a  chill,  followed  by  high  fever,  rapid  heart 
action,  headache,  general  malaise,  and  often  restlessness  and  delirium. 
Accompanying  these  there  is  pain  at  the  seat  of  infection,  with  swell- 
ing, redness,  and  other  evidences  of  inflammation.  If  the  septic  focus 
is  promptly  opened  and  disinfected,  the  symptoms  rapidly  subside. 
In  the  septicemic  type  of  general  sepsis  the  symptoms  are  at  first 
similar  to  those  of  simple  septic  intoxication,  but  are  not  relieved  by 
the  opening  and  disinfection  of  the  primary  focus.  On  the  contrary, 
there  is  continued  high  fever,  with  great  prostration  and  progressive 
loss  of  flesh  and  strength.  Nausea  and  vomiting,  diarrhea,  albumin- 
uria, and  symptoms  of  uremia  may  appear.  Delirium  is  marked  and 
coma  may  develop  shortly  before  death.  In  the  pyemic  type  of  the 
disease  the  onset  is,  as  a  rule,  more  gradual;  and  if  preceded  by 
symptoms  of  intoxication  from  an  unrelieved  septic  focus  the  first 
sign  of  the  pyemic  process  may  be  the  occurrence  of  a  metastatic 
focus  in  some  remote  portion  of  the  body.  In  the  majority  of  in- 
stances, however,  there  are  chills,  irregular  fever  with  marked  daily 
remissions  and  profuse  sweats.  The  skin  becomes  sallow  and  evi- 
dences of  metastatic  abscesses  develop  in  the  lungs,  liver,  brain, 
kidneys,  joints,  and  on  the  surface  of  the  body.  In  all  three  t}pes 
of  the  disease  leukocytosis  is  present,  and  in  the  two  last  ulcerative 
endocarditis  is  apt  to  develop. 

Prognosis. — In  simple  intoxications  the  prognosis  is  generally 
favorable  if  the  focus  can  be  found  and  removed.  In  the  septicemic 
and  pyemic  types  the  prognosis  is  decidedly  unfavorable;  the  former 
generally  die  in  from  ten  to  fourteen  days;  the  latter,  in  from  two  to 
eight  weeks. 

Treatment. — The  treatment  of  general  sepsis  consists  in  measures 
to  remove  the  focus  of  infection,  hasten  the  elimination  of  the  poison, 
and  to  increase  the  natural  resistance  of  the  patient.  Local  measures 
consist  in  opening  and  evacuating  the  focus  of  infection,  the  employ- 


40  ACUTE  INFECTIOUS  SURGICAL  DISEASES 

ment  of  drainage  and  asepsis.  Removal  of  an  infected  bone  or  organ, 
or  amputation  of  an  extremity  may  be  necessary. 

Of  the  bacteriolytic  sera,  few  have  given  promise  of  yielding  favor- 
able results.  The  antigonococcic  serum  of  Torrey,  Rogers  and  Beebe 
has  produced  benefit  in  infections  by  this  organism,  which  has  been 
most  evident  in  the  local  manifestations — as  arthritis.  Antistrepto- 
coccus  serum  has  been  employed  for  some  time  with  reports  of  a  few 
favorable  results.  Failure  in  the  past  to  derive  beneficial  results  from 
the  use  of  this  serum  in  all  probability  arises  from  the  fact  that  there 
is  a  scarcity  of  complement  available  at  the  time  of  injection  to  activate 
the  serum  employed.  This  may  be  overcome  by  deriving  the  thera- 
peutic sera  from  a  species  of  animal  closely  allied  to  man  or  by  in- 
creasing the  amount  of  complement  in  the  blood  of  the  patient. 
Abbott,  Longcope,  and  others  have  already  shown  that  the  amount  of 
complement  in  the  blood  may  be  reduced  by  alcohol  and  various 
chronic  as  well  as  acute  diseases.  The  use  of  bacterial  vaccines,  while 
productive  of  beneficial  results  in  some  local  infections,  have  given 
little  promise  of  help  in  systemic  infections. 

Recently  Hiss  has  reported  beneficial  results  in  staphylococcus, 
streptococcus,  pneumococcus,  and  meningococcus  infections  from 
the  subcutaneous  injection  of  extracts  of  leukocytes.  The  action 
of  these  extracts  is  believed  to  be  due  to  endo-antitoxins  liberated 
from  the  disintegrated  leukocytes.  It  is  possible  that  the  amount 
of  complement  is  also  thus  increased. 

ERYSIPELAS. 

Erysipelas  is  an  acute  infectious  disease,  characterized  by  a  spread- 
ing inflammation  of  the  skin,  induced  by  Streptococcus  pyogenes. 
There  is  a  tendency  to  spontaneous  recovery.  The  disease  is  accom- 
panied by  febrile  disturbances. 

Etiology. — The  inciting  bacterial  agent  is  a  streptococcus,  as  was 
shown  by  Fehleisen,  in  1884.  He  obtained  pure  culture  of  the  organ- 
ism and  named  it  Streptococcus  erysipelas.  It  is  now  generally 
assumed  that  this  organism  and  Streptococcus  pyogenes  are  the 
same. 

Erysipelas  is  endemic  in  most  countries,  and  is  particularly  fre- 
quent in  the  spring.  Chronic  alcoholism,  chronic  nephritis,  and  other 
diseases  are  predisposing  factors.  The  most  frequent  point  of  entrance 
for  the  streptococcus  is  through  a  wound.  It  is  often  impossible, 
however,  to  find  the  point  of  entrance.  A  small  fissure,  occurring 
in  cold  weather  around  the  nose  and  angles  of  the  mouth,  has  often 
been  observed  as  a  starting  point  for  the  infection.  In  the  newborn 
— erysipelas  neonatorum — infection  of  the  cord-stump  was  formerly 
frequent. 

Morbid  Anatomy. — The  lesion  is  characterized  by  inflammation  of 
the  skin,  with  considerable  exudation  of  fluid.     The  streptococci  are 


ERYSIPELAS  41 

present  in  large  numbers  in  the  lymphatics  of  the  skin  and  underlying 
tissues,  especially  in  the  zone  of  spreading  inflammation.  They  are 
also  present  in  the  adjacent  non-inflamed  parts.  As  the  inflammatory 
process  advances  the  cocci  gradually  die,  and  further  extension  at  the 
periphery  ceases.  In  some  cases  there  may  be  suppuration.  The 
streptococci  may  invade  the  various  organs  of  the  body,  thus  inducing 
septic  complications. 

Symptoms. — Constitutional  symptoms  are  usually  manifest  before 
the  local  symptoms.  There  is  often  a  rigor  followed  by  an  elevation  in 
temperature.  Some  enlargement  of  the  lymph  nodes  may,  perhaps, 
be  detected  in  the  region  of  the  wound,  if  any  exists.  Soon  there  is  a 
feeling  of  increased  tension  in  the  wound,  which  is  hot,  tender,  and  red. 
With  the  appearance  of  exudation  the  skin  becomes  red,  smooth, 
tense,  and  edematous.  Vesicles  or  blebs  may  appear.  The  swelling 
extends  and  the  local  redness  shows  a  tendency  to  spread.  The  line 
of  demarcation  is  sharp.  If  present  on  the  extremities,  the  inflamma- 
tory process  travels  toward  the  trunk;  and  if  on  the  face  it  often  pro- 
gresses towards  the  scalp  to  halt  at  the  hair  line.  If  the  scalp  is  in- 
vaded it  frequently  involves  the  entire  scalp  to  halt  again  at  the  hair 
line  posteriorly.  If  the  disease  spreads  beyond  the  hairy  scalp  it  is 
apt  to  sweep  downwards  over  the  back,  fading  gradually  away.  While 
in  the  scalp,  local  tenderness  is  marked,  a  physical  sign  often  at  vari- 
ance with  the  signs  of  the  disease  elsewhere  on  the  body.  In  wander- 
ing erysipelas  the  process  may  involve  large  areas.  In  the  facial  form 
the  swelling  may  be  enormous,  so  that  the  eyes  are  closed,  the  nose 
enlarged,  and  the  lips  much  thickened.  The  leukocyte  count  is  from 
10,000  to  20,000.  Delirium  may  be  present.  At  the  end  of  four  or  five 
days  the  temperature  falls.  Erysipelas  may  reappear  in  the  affected 
part  or  elsewhere.  This  tendency  to  recurrence  is  characteristic  of  the 
disease.  At  the  end  of  ten  days  or  two  weeks  recovery  is  usually  com- 
plete. Some  patients  suffer  from  recurring  attacks  at  certain  times 
of  the  year  on  particular  parts  of  the  body.  Among  the  complications 
may  be  mentioned  spreading  cellulitis  (phlegmonous  erysipelas); 
sloughing  which  may  be  extensive;  septicemia,  endocarditis,  pneu- 
monia, meningitis,  and  nephritis. 

Prognosis. — The  prognosis  is  generally  good.  The  hospital  mor- 
tality is  about  7  per  cent.,  but  in  private  practice  the  death-rate  is 
much  lower. 

Treatment. — Isolation  is  regarded  by  some  as  important.  Trans- 
mission of  the  disease  by  contact  is  of  frequent  occurrence,  and 
those  in  attendance  upon  a  case  should  not  perform  surgical  opera- 
tions or  attend  cases  of  confinement.  Drugs  are  not  needed,  except 
in  the  old  and  feeble,  to  whom  stimulants  may  be  given.  Large  doses 
of  the  tincture  of  chloride  of  iron,  sometimes  with  quinine,  have  been 
recommended,  but  their  value  is  doubtful.  The  local  application  of 
ichthyol,  of  weak  solutions  of  carbolic  acid  or  aluminium  acetate  is 
frequently   serviceable,   while   cold   boric   acid   solution,  in  frequent 


42  ACUTE  INFECTIOUS  SURGICAL  DISEASES 

application  in  moist  gauze,  gives  the  most  comfort.  It  is  important 
to  remember  that  the  disease  is  self-limited  and  generally  runs  its 
course  despite  any  treatment. 


ERYSIPELOID. 

This  is  a  form  of  dermatitis  occurring  usually  on  the  finger  or 
hand  from  inoculation  by  decomposing  animal  matter,  and  most 
frequently  seen  in  cooks,  butchers,  and  fish  dealers.  Rosenbach 
attributes  the  disease  to  an  organism  of  the  cladothrix  group.  The 
heat,  swelling,  pain,  and  redness  are  marked — the  latter  occurring 
at  first  as  a  line  of  demarcation,  which  may  slowly  spread  over  the 
entire  hand.  Involvement  of  the  lymphatic  ducts  and  glands  may 
occur,  but  systemic  symptoms  do  not  follow.  The  treatment  is 
largely  expectant. 

TETANUS    (LOCKJAW). 

Tetanus  is  an  infectious  disease  usually  following  traumatic  injur- 
ies, and  is  characterized  by  tonic  spasms  of  the  muscles,  beginning 
with  those  of  the  jaw  and  neck,  and  progressively  affecting  the  muscles 
of  the  trunk  and  extremities.  The  disease  is  incited  by  the  tetanus 
bacillus. 

Etiology. — The  general  association  of  the  disease  with  the  pres- 
ence of  wounds  suggested  its  infectious  nature  a  long  time  ago.  Carle 
and  Rattone  in  1884  announced  that  they  had  induced  the  disease 
in  rabbits  by  inoculations  with  material  from  a  wound  in  an  individual 
suffering  from  tetanus.  The  following  year  Nicolaier  established  the 
fact  that  inoculations  of  animals  with  earth  from  various  sources 
often  were  followed  by  the  development  of  tetanus.  He  described  the 
tetanus  bacillus,  but  was  unable  to  isolate  it  in  pure  culture;  this 
was  done  subsequently  by  Kitasato  in  1889.  It  is  slightly  motile. 
It  readily  forms  spores,  and  then  presents  the  very  characteristic 
"drumstick"  appearance.  The  natural  habitat  of  the  organism  has 
been  shown  to  be  the  earth.  It  is  found  especially  in  garden  soil  and 
in  the  contents  of  dung  heaps,  where  it  probably  exists  as  a  sapro- 
phyte. By  the  employment  of  appropriate  methods  for  the  growth 
of  anaerobic  bacteria  it  may  be  cultivated  artificially.  The  spores  are 
very  resistant,  and  may  withstand  boiling  for  five  minutes;  they  may 
also  be  kept  alive  in  a  dry  condition  for  many  months  without  losing 
their  virulence.  Their  resistance  to  antiseptics  is  considerable.  The 
disease  may  be  induced  experimentally  in  animals  by  the  usual  methods 
of  inoculation.  The  organisms  remain  confined  to  the  point  of  inocu- 
lation. Feeding  experiments  have  been  unsuccessful.  The  incuba- 
tion period  in  animals  varies  from  several  hours  to  several  days.  The 
symptoms  observed  in  inoculated  animals  are,  in  the  main,  those  of 
the  disease  in  man,  the  spasms  beginning  with  the  muscles  nearest 
the  seat  of  inoculation,  but  chiefly  the  muscles  of  mastication  are 


TETANUS  43 

involved.  The  disease  is  due  to  absorption  of  the  toxic  products  of 
the  organism  from  the  wound  which  contains  them.  A  study  of  the 
tetanus  toxin  shows  that  it  is  extremely  poisonous,  and  that  its  intro- 
duction into  the  body  is  followed  by  the  development  of  tonic  spasms. 
The  exact  chemical  nature  of  the  toxin  is  unknown.  Artificial  im- 
munization of  animals  against  tetanus  has  been  studied,  and  by  the 
injection  of  progressively  increasing  doses  of  tetanus  toxin  a  moderate 
immunity  may  be  produced.  Inoculation  of  animals  with  attenuated 
cultures  has  also  been  followed  by  immunity.  The  degree  of  immunity 
acquired  exists  for  several  months.  For  a  time  the  immune  serum  pro- 
tects susceptible  animals  against  tetanus.  It  is  especially  efficient  if 
injected  before  or  soon  after  the  inoculation,  the  degree  of  success 
depending  largely  upon  the  time  that  has  elapsed  since  inoculation. 
When  the  symptoms  of  the  disease  are  fully  manifested,  success  is 
assured  in  only  a  small  number  of  cases.  There  is  no  evidence  that 
the  antitetanic  serum  inhibits  the  growth  of  the  bacilli. 

Although  tetanus  may  occur  anywhere,  it  has  not  everywhere 
been  observed  with  the  same  frequency.  It  is  more  common  in  hot 
than  in  temperate  climates,  and  in  the  colored  than  in  the  Caucasian 
race.  Lombard  states  that  in  Iceland  one-third  of  the  general 
mortality,  especially  in  the  newly  born,  is  from  tetanus.  It  has  been 
studied  in  epidemic  form  in  infants  (trismus  nascentium).  Out  of 
17,650  infants  born  (before  1882)  in  the  Rotunda  Hospital,  Dublin, 
Clarke  estimates  that  2944  died  of  tetanus.  In  some  of  the  West 
Indian  Islands  more  than  50  per  cent,  of  the  mortality  among  the 
negro  children  has  been  due  to  this  cause.  Formerly  the  disease  was 
very  prevalent  on  the  eastern  end  of  Long  Island. 

It  is  probable  that  the  disease  is  always  traumatic  in  origin.  The 
wound  of  inoculation  is  sometimes  too  small  to  be  found.  Of  1751 
cases  of  tetanus,  41.5  per  cent,  followed  wounds  of  the  hand  or  foot, 
many  of  which  were  the  result  of  injuries  from  toy  pistols;  wounds 
of  the  limbs,  face,  and  scalp  are  next  in  frequency.  Infection  is 
more  apt  to  occur  after  punctured  and  contused  than  after  incised 
wounds. 

Pathologic  Anatomy. — The  lesions  are  few  and  not  characteristic. 
The  recorded  autopsies  mention  inflammation  and  degeneration  of 
peripheral  nerves,  meningeal  hemorrhages,  and  inflammatory  changes 
in  the  sympathetic  nervous  system.  Goldscheider  and  Flatau  have 
described  changes  in  the  motor  cells  of  the  anterior  horn  which  they 
consider  characteristic.  The  cerebrospinal  fluid  in  cases  of  tetanus 
has  been  shown  by  Stintzing  to  contain  tetanus  toxin.  This  author 
sums  up  his  research  concerning  the  pathogenesis  of  the  infection  in 
the  following:  "The  tetanus  bacillus  produces  toxins  at  the  seat 
of  infection.  These  toxins  partly  enter  the  circulation  (in  animals 
surely),  and  may  become  active  through  this  channel;  as  a  rule,  how- 
ever, the  toxins  are  carried  along  the  nearest  nerves,  presumably  in 
the  meshes  of  the  perineurium  and  endoneurium,  to  the  spinal  cord. 


44  ACUTE  INFECTIOUS  SURGICAL  DISEASES 

On  reaching  the  subarachnoidal  space  of  the  cord  they  produce  in 
animals  their  toxic  action,  at  first  at  the  point  of  entrance  into  the 
cord,  and  so  cause  the  'local'  tetanus.  If  sufficient  poison  is  brought 
to  the  spinal  cord,  it  produces,  next,  a  reactionary  and,  finally,  general 
tetanus." 

Symptoms. — Most  of  the  cases  have  an  incubation  period  of  about 
ten  days;  certainly  four-fifths  of  the  cases  develop  symptoms  before 
the  fifteenth  day.  Acute,  chronic,  and  cephalic  forms  of  tetanus  are 
described. 

In  acute  tetanus  the  onset  may  be  abrupt,  but  more  often  malaise, 
headache,  chilly  feelings  or  actual  rigors  occur,  with  some  stiffness 
in  the  neck  or  a  feeling  of  tightness  in  the  jaws.  Tonic  spasm  of  the 
masseters  (lockjaw)  generally  develops,  and  the  eyebrows  may  be 
raised  and  the  angles  of  the  mouth  drawn  out,  so  that  the  face  assumes 
the  so-called  sardonic  grin — risw  sardonicus.  Finally,  the  muscles 
of  the  whole  body  may  be  affected,  but  those  of  back  are  most  involved, 
so  that  during  the  spasm  the  body  may  be  thrown  into  condition  of 
opisthotonos.  Flexion  to  one  side,  pleurosthotonos,  is  less  common. 
Forward  bending,  emprosthotonos,  is  seldom  seen.  The  arms,  as  a  rule, 
are  less  affected.  Paroxysms  last  a  variable"  time,  during  which  there 
may  be  spasm  of  the  glottis,  dyspnea,  and  cyanosis.  The  paroxysms 
often  are  associated  with  agonizing  pain.  Usually  the  patient  is 
covered  with  perspiration.  Fever  may  be  absent,  slight,  or  in  some 
cases  the  temperature  reaches  105°  or  106°  F.  The  mind  is  not  affected. 
Death  generally  occurs  during  a  paroxysm,  either  from  heart  failure 
or  asphyxia;  in  other  cases  it  may  be  due  to  exhaustion.  The  disease 
is  usually  fatal  in  about  10  days. 

In  chronic  tetanus  the  symptoms  are  essentially  the  same  as  those 
observed  in  the  acute  form,  but  less  severe.  The  disease  may  be 
prolonged  for  weeks. 

Cephalic  tetanus  is  characterized  by  stiffness  of  the  muscles  of  the 
jaw  and  paralysis  of  the  facial  nerve  on  the  same  side  as  the  injury. 

Diagnosis. — In  well-developed  cases  there  is  little  chance  for  error 
in  diagnosis. 

Prognosis. — The  prognosis  is  based  mainly  on  the  period  of  incuba- 
tion and  the  severity  of  the  symptoms.  Statistics  show  that  when  the 
period  of  incubation  is  less  than  ten  days  the  mortality  is  very  high 
(85  per  cent.);  and  also  that  the  prognosis  improves  with  each  day 
beyond  this  period.  Since  the  introduction  of  the  antitoxin  treatment 
the  mortality  has  been  reduced  from  about  90  to  40  per  cent. 

Treatment. — In  this  we  should  endeavor  (1)  to  destroy  the  bacteria 
at  the  seat  of  infection  and  thereby  prevent  a  further  production  of 
toxins;  (2)  to  eliminate  from  the  body  the  toxins  already  elaborated 
from  the  primary  lesion;  (3)  to  neutralize  and  render  innocuous  the 
poison  already  absorbed;  (4)  to  immunize  the  body  after  infection 
has  taken  place;  (5)  to  overcome  the  symptoms  induced  by  the  action 
of  the  toxins.    Thorough  disinfection  of  the  wound  is  very  important. 


HYDROPHOBIA  45 

The  object  should  be  not  only  to  destroy  the  tetanus  bacillus  or  its 
spores,  but  also  saprophytic  and  pyogenic  bacteria,  which  the  experi- 
ments of  Vaillard  and  Rouget  have  shown  to  favor  development  of 
the  tetanus  bacillus.  Of  the  antiseptics  most  frequently  used  may 
be  mentioned:  iodine  in  5  or  10  per  cent,  solution,  also  nitrate  of 
silver  2  or  4  per  cent.;  bichloride  of  mercury  solution  (1  to  1000),  to 
which  has  been  added  5  per  cent,  tartaric  acid  or  0.5  per  cent,  hydro- 
chloric acid. 

The  results  following  the  use  of  tetanus  antitoxin  for  curative 
purposes  were  rather  disappointing  when  its  administration  was 
confined  to  the  subcutaneous  methods.  Recent  procedures  involving 
the  direct  contact  of  antitoxin  and  the  part  of  the  nervous  system 
affected,  have  yielded  results  which  are  far  more  promising. 

Park  and  Nicoll  have  reported  a  suggestive  series  of  experiments 
on  animals  where  the  antitoxin  was  used  intraspinally.  In  a  similar 
form  of  treatment  they  report  few  human  cases  that  recovered.  They 
advise  the  intraspinal  injection  at  the  first  possible  moment  following 
the  onset  of  tetanus,  of  from  three  to  five  thousand  units  of  antitoxin. 
This  antitoxin  should  be  introduced  by  gravity  and  very  slowly,  if 
possible  while  the  patient  is  under  an  anesthetic.  If  the  amount  of 
spinal  fluid  is  small  the  quantity  of  antitoxin  must  be  reduced. 

In  addition  to  the  use  of  tetanus  antitoxin,  every  effort  must  be 
made  to  prevent  the  occurrence  of  convulsions  by  the  maintenance 
of  absolute  quiet  and  the  administration,  when  necessary,  of  bromides, 
chloral,  morphine,  or  opium. 

HYDROPHOBIA. 

Hydrophobia  is  an  infectious  disease,  occurring  chiefly  among  the 
carnivora,  especially  the  dog  and  wolf.  The  disease  is  also  known  as 
rabies  and  lyssa.  Infection  is  carried  by  the  bite  of  a  rabid  animal  or 
by  a  wound  being  licked  by  such. 

Etiology. — Rabies  occurs  in  all  countries.  In  man  the  period  of 
incubation  varies  from  fifteen  days  to  seven  or  eight  months  or  longer, 
but  the  average  period  may  be  taken  as  forty  days.  The  differences 
in  the  incubation  period  are  partly  due  to  the  age  of  the  patient,  the 
part  involved,  and  the  severity  of  the  wound.  In  children  the  period 
of  incubation  is  more  brief  than  in  adults.  Wounds  about  the  face  and 
head  are  regarded  as  especially  dangerous.  The  bite  of  the  wolf  is 
more  serious  than  of  other  animals. 

The  infective  agent  in  the  saliva  of  the  rabid  animal  passes  from 
the  wound,  and  is  carried  along  the  nerves  to  the  central  nervous 
system.  It  may  be  present  in  the  saliva  of  the  dog  from  three  to  five 
days  before  the  symptoms  of  the  disease  appear  in  the  dog. 

In  1903  Negri  found  in  the  ganglion  cells  of  the  Hippocampus 
major  cerebral  cortex,  medulla,  and  elsewhere  in  the  nervous  system 
rounded   bodies    1  to   23/x  in   diameter   resembling  protozoa,  which 


46  ACUTE  INFECTIOUS  SURGICAL  DISEASES 

stain  readily  and  consist  of  a  rounded  or  oval  homogeneous  basement 
substance  containing  a  central  body  surrounded  by  variously  shaped 
granules. 

These  "Negri  bodies"  have  been  found  in  nearly  all  cases  of  street 
rabies  examined  for  them,  and  in  no  infective  or  other  disease  than 
rabies,  and  therefore  undoubtedly  occupy  a  specific  etiological  rela- 
tionship to  hydrophobia. 

Morbid  Anatomy. — The  lesions  are  limited  to  the  central  nervous 
system.  In  the  medulla  and  pons,  and  occasionally  in  the  spinal 
cord,  may  be  seen  small  hemorrhages,  accumulation  of  leukocytes  in 
the  perivascular  spaces  about  the  bloodvessels  and  ganglion  cells. 
Some  of  the  ganglion  cells  show  chromatolysis,  and  the  Negri  bodies 
may  occupy  central  or  peripheral  positions  in  them. 

Symptoms. — Three  stages  are  described.  First,  prodromal,  in  which 
there  may  be  pain  in  the  wound  and  in  the  nerves  along  the  injured 
limb.  Manifestations  of  nervous  irritability  soon  appear,  associated 
with  an  increase  in  the  reflexes.  There  may  be  slight  fever.  The 
patients  at  this  period  are  often  melancholic,  and  there  may  already 
be  some  suspicion  of  difficulty  in  swallowing.  Second,  stage  of  excite- 
ment, in  which  there  are  great  excitability  and  hyperesthesia.  There 
are  spasms,  especially  of  the  muscles  of  deglutition  and  respiration. 
Delirium  may  be  present.  Spasms  may  be  induced  by  the  slightest 
causes.  In  the  intervals  the  patient  is  clear-minded  and  calm.  The 
temperature  is  between  95.5°  and  102°  F.  In  two  or  three  days  the 
patient  passes  into  the  third  or  paralytic  stage,  in  which  the  reflexes 
are  diminished,  weakness  and  paralysis  may  be  present,  convulsions 
occur,  and  finally  coma  and  death  supervene.  The  duration  of  the 
disease  is  from  five  to  ten  days.  Death  invariably  results  when  once 
the  disease  is  established. 

Whenever  a  person  is  bitten  by  an  animal  that  is  suspected  to  be 
suffering  from  rabies,  the  animal  may  be  carefully  watched  for  mani- 
festations of  the  disease.  Death  will  usually  take  place  within  five 
days.  If  the  animal  has  been  killed,  pieces  of  the  cord  or  medulla  may 
be  taken  and  inoculated  beneath  the  dura  of  a  rabbit.  Symptoms  will 
appear  within  three  weeks.  Recently  it  has  become  the  common 
procedure  to  kill  the  suspected  animal  and  determine  the  diagnosis  of 
rabies  by  the  presence  of  Negri  bodies  in  the  brain  or  medulla.  In  this 
way  a  positive  diagnosis  may  be  made  with  the  least  loss  of  time. 

Treatment. — Before  Pasteur's  method  was  developed,  the  only  means 
by  which  the  development  of  the  disease  could  be  prevented  in  those 
who  had  been  bitten  by  a  rabid  animal  was  cauterization  of  the  wound. 

The  very  long  incubation  period  in  the  human  being  of  from  fifty  to 
ninety  days  in  the  average  case  affords  time  for  artificial  immuniza- 
tion against  the  disease.  Really  wonderful  results  have  been  obtained 
by  this  procedure,  if  treatment  is  commenced  in  time.  Following  the 
onset  of  symptoms  the  disease  is  regularly  fatal. 

Immunity  is  obtained  by  daily  injections  of  toxin  of  increasing 


ANTHRAX  47 

virulence.  A  relatively  inert  virus  is  used  in  the  initial  dose  until  on 
or  about  the  eighteenth  day  full  strength  virus  is  injected.  Therefore, 
by  the  time  the  disease  would  appear  the  resistance  will  be  sufficient 
to  withstand  it. 


ANTHRAX  (MALIGNANT  PUSTULE,  WOOL  SORTER'S  DISEASE). 

Anthrax  is  an  acute,  local,  or  general  infectious  disease,  induced 
by  Bacillus  anthracis.  It  occurs  with  great  frequency  among  the 
herbivora,  especially  sheep  and  cattle,  from  which  it  is  readily  com- 
municated, directly  or  indirectly,  to  man. 

Etiology. — It  is  to  the  studies  of  Rayer  and  Davaine,  Pollender, 
Pasteur,  and  Koch  that  we  owe  our  knowledge  of  the  infectious  agent 
of  anthrax.  The  anthrax  bacillus  readily  forms  spores,  which  are 
very  resistant  to  heat  and  chemical  agents.  They  withstand  the 
temperature  of  boiling  water  for  several  minutes.  They  are  not 
killed  by  gastric  juices.  Outside  of  the  body  the  spores  probably  live 
for  a  long  period  of  time. 

Anthrax  is  more  commonly  met  with  in  Europe  and  Asia  than  in 
this  country.  Animals  are  sometimes  inoculated  by  the  bites  of 
insects,  but  more  often  by  swallowing  the  infectious  agent.  Those 
who  are  engaged  in  handling  hides  are  often  infected  on  the  hands 
or  face.  Butchers  sometimes  are  infected  by  handling  contaminated 
meat.  Wool-sorters,  on  the  other  hand,  are  more  liable  to  inhalation 
infection. 

Symptoms. — Several  varieties  of  the  disease  are  recognized,  accord- 
ing to  the  portal  of  entry  of  the  anthrax  bacillus.  The  infection  may 
be  external,  through  the  skin;  internal,  through  the  respiratory  organs 
or  intestine. 

The  characteristic  lesion  of  the  external  form  is  the  pustule,  which 
is  usually  situated  on  the  hands,  arms,  face,  or  neck.  The  period  of 
incubation  is  two  or  three  days.  The  external  lesion  begins  as  a  papule, 
which  soon  becomes  vesicular.  The  tissues  become  infiltrated  with 
exudate,  so  that  within  forty-eight  hours  there  is  a  dark-brown  or 
brownish-red  eschar,  often  surrounded*  by  a  fine  vesicular  eruption. 
The  lymph  nodes  of  the  region  become  enlarged  and  painful.  There 
is  a  variable  amount  of  fever,  although  the  temperature  may  fall  to 
subnormal  before  death  occurs.  Death  may  occur  within  three  or 
four  days.  In  the  majority  of  anthrax  infections  the  symptoms  are 
less  severe.  In  these  cases  there  may  only  be  slight  swelling  about  the 
local  lesion. 

The  disease  sometimes  appears,  especially  about  the  face,  as  an 
extensive  edema  without  papules  or  vesicles.  This  is  known  as  malig- 
nant anthrax  edema.  The  fatal  cases  of  external  anthrax  are  generally 
those  in  which  infection  has  taken  place  on  the  face  or  neck. 

Intestinal  anthrax  results  from  swallowing  infected  material.  There 
may  be  a  chill,  often  followed  by  diarrhea,  fever,  and  other  evidences 


-48  ACUTE  INFECTIOUS  SURGICAL  DISEASES 

of  an  acute  infectious  disease.  The  spleen  is  enlarged.  The  bacilli 
may  be  found  in  the  blood  shortly  before  death.  In  the  respiratory 
type  the  symptoms  are  usually  severe  from  the  beginning — chills, 
pain  in  chest,  back,  and  legs,  hurried  respiration,  fev?r,  and  cough, 
with  signs  of  bronchitis.     Death  may  occur  within  thirty-six  hours. 

The  outlook  is  best  for  cases  of  external  anthrax,  especially  if  the 
infection  occurs  in  the  extremities.  In  this  class  the  mortality  does 
not  exceed  5  per  cent.  When  the  lesion  is  on  the  neck  or  face  the 
mortality  rises  to  about  30  per  cent.  Internal  anthrax  shows  a  much 
higher  mortality. 

Treatment. — The  primary  lesion  in  its  earliest  stages  may  be  de- 
stroyed by  the  Paquelin  cautery  or  caustics.  At  one  period  excision  of 
the  pustule  was  practised.  More  recently  this  procedure  has  been 
advised  against,  since  the  invasion  of  the  body  at  large  seems  to  be 
more  apt  to  occur.  Disinfection  of  the  wounds  by  means  of  packing 
with  wet  formalin  gauze  (1  to  50)  is  the  most  effective  treatment.  The 
toxemia  should  be  combatted  with  stimulants,  food,  and  measures  to 
promote  rapid  elimination  of  the  poison  through  the  skin,  kidneys, 
or  alimentary  canal. 

MALIGNANT    EDEMA. 

Malignant  edema  is  an'  acute,  local,  infectious  process,  accom- 
panied by  tissue  emphysema  and  gangrene,  and  caused  by  the  bacillus 
of  malignant  edema,  which  is  found  in  garden  soil,  dung,  and  various 
putrefying  substances. 

The  bacillus  is  anaerobic  and  under  unfavorable  conditions  of 
growth  develops  large  spores,  which  have  a  high  power  of  resistance. 

The  infection  may  be  introduced  by  a  sharp-pointed  garden  tool  or 
even  a  needle,  but  the  disease  occurs  most  commonly  when  dirt  con- 
taining the  bacillus  enters  a  severely  contused  wound.  Particularly 
is  this  true  in  extensive  injuries  such  as  gun-shot  wounds  combined 
with  loss  of  blood ;  under  these  circumstances  the  invasion  of  the  body 
by  the  organism  is  more  likely  to  occur. 

Early  in  the  process  the  skin  becomes  a  dirty,  brownish-red  color, 
with  distended  veins  filled  with  stagnating  blood.  The  tissues  become 
edematous  and  infiltrated  with  gases,  giving  rise  to  emphysematous 
crepitation  on  palpation.  A  scant  serosanguineous  discharge  exudes 
from  the  wound,  accompanied  by  a  characteristic,  offensive  odor. 
Gangrene  develops  in  the  wound  and  spreads  rapidly.  The  neighboring 
lymph-nodes  are  swollen  and  the  patient  shows  signs  of  septic  absorp- 
tion— fever,  prostration,  dry,  heavily-coated  tongue,  rapid  pulse,  with 
delirium  followed  by  coma.  Death  may  occur  in  from  forty-eight  hours 
to  three  or  four  days,  an  entire  extremity  being  meanwhile  involved 
in  the  disease. 

Prognosis. — The  prognosis  is  bad.  The  mild  cases  occasionally 
recover  after  multiple  incision  and  asepsis;  but  amputation  performed 


GLANDERS  l!) 

early  and  as  high  up  on  the  extremity  as  possible,  is  usually  indicated. 
In  animals,  immunity  to  this  infection  has  been  produced  by  repeated 
injections  of  sterilized  or  filtered  cultures  of  the  organism  or  the  filtered 
serum  from  immune  animals. 

GLANDERS    (FARCY). 

Glanders  is  an  infectious  disease  which  chiefly  affects  horses,  mules, 
and  asses.  It  is  found  also  in  man  as  a  result  of  direct  inoculation 
on  some  wound  of  the  skin  or  other  part  with  the  discharges  or  diseased 
tissues  from  an  affected  animal.  Therefore  it  is  especially  frequent 
among  grooms  and  others  whose  work  brings  them  into  contact  with 
horses. 

Etiology. — The  bacillus  of  glanders  was  discovered  by  Loeffler  and 
Schutz. 

Morbid  Anatomy. — When  limited  to  the  nose  the  disease  is  called 
(/hinder*;  but  if  present  beneath  the  skin,  it  is  designated  farcy. 
The  lesions  consist  of  granulomatous  tumors,  which  tend  to  break 
down  rapidly  and  form  ulcers  on  mucous  membranes  and  abscesses 
beneath  the  skin.  The  lungs  are  almost  invariably  involved.  Less 
frequently  other  organs  show  characteristic  lesions.  These  consist 
of  larger  and  smaller  white  or  yellowish-white  nodules  sharply  cir- 
cumscribed and  surrounded  by  a  hemorrhagic  zone.  Beyond  this  an 
area  of  pallor  is  sometimes  seen.  They  are  situated  around  the  blood- 
vessels, and  consist  of  polymorphonuclear  leukocytes  with  broken 
down  cells. 

Symptoms. — Glanders  infection  in  man  is  either  acute  or  chronic 
in  its  manifestations. 

Acute  Glanders. — The  incubation  period  is  generally  three  to  four 
days.  At  the  inoculation  seat  there  are  swelling,  redness,  and  signs 
of  lymphatic  involvement.  In  three  or  four  days  the  nodules  in 
the  mucous  membranes  of  the  nose  begin  to  break  down,  with  the 
discharge  of  muco-pus.  There  is  considerable  swelling  of  the  nose, 
and  an  eruption  of  papules  and  pustules  is  common  on  the  face.  The 
lymph  nodes  of  the  neck  are  usually  swollen.  The  disease  runs  a  course 
of  about  ten  days,  many  of  the  cases  dying  with  pneumonia.  All  the 
cases  terminate  fatally. 

Chronic  Glanders. — This  may  last  a  long  time,  and  the  diagnosis 
is  not  often  made.  The  symptoms  are  those  of  a  chronic  coryza. 
Ulcers  may  be  found  in  the  nose. 

Acute  Farcy. — This  is  the  result  of  inoculation  into  the  skin.  Intense 
local  inflammation  occurs;  the  lymphatics  become  involved,  and 
along  their  course  nodules — farcy  buds — may  be  felt.  Many  of  these 
suppurate.  In  addition  to  these  lesions  often  there  is  a  pustular  erup- 
tion resembling  that  of  varicella.  The  disease  pursues  a  febrile  course 
like  that  of  severe  typhoid  or  a  septic  infection.  Pains  and  swellings 
in  the  joints  may  be  present.  The  nasal  mucous  membrane  is  free 
4 


50  ACUTE  INFECTIOUS  SURGICAL  DISEASES 

from  ulcers.  The  prognosis  is  bad,  most  of  the  cases  dying  within  two 
weeks. 

Chronic  Farcy. — In  this  form  the  nodular  tumors  are  usually  found 
in  the  extremities.  Many  of  them  break  down,  resulting  either  in 
abscess  or  ulcer  formation.  The  lymphatics  are  not  specially  involved. 
Recovery  is  possible. 

Diagnosis. — The  diagnosis  may  be  made  by  Straus'  inoculation 
test.  It  consists  in  the  peritoneal  inoculation  of  male  guinea-pigs 
with  suspected  material.  If  the  inoculated  material  contain  Bacillus 
mallei  there  will  be  swelling  of  the  testes  as  early  as  the  third  day, 
and  swelling  and  ulceration  of  .the  scrotum  by  the  fifth  or  sixth  day. 
Autopsy  often  shows  the  presence  of  glanders  nodules  in  the  omentum, 
spleen,  and  liver,  and  an  inflammatory  purulent  or  caseous  exudate 
in  the  tunica  albuginea.  Mallein — the  glanders  bacillus  toxin — is  now 
used  for  diagnostic  purposes  in  horses. 

Treatment. — The  lesion  should  either  be  excised  or  cauterized  if 
the  case  is  seen  early.  The  farcy  buds  should  be  opened  and  disin- 
fected with  formalin. 

BACILLUS    AEROGENES    CAPSULATUS    (GAS    BACILLUS) 
INFECTIONS. 

It  is  known  that  various  bacteria  may  be  concerned  in  producing 
gas  in  tissues  where  it  does  not  normally  exist.  From  the  investi- 
gations of  the  last  ten  years,  however,  we  know  that  Bacillus  aerogenes 
capsulatus,  which  was  discovered  by  Welch  in  1891,  is  the  one  most 
frequently  associated  with  such  conditions.  This  is  an  anaerobic 
bacillus.  Spore-formation  is  inconstant.  The  natural  habitat  of  the 
organism  is  the  soil  and  intestinal  canal.  Brooks  has  also  found  it  in 
the  male  urethra,  the  vagina,  and  nasal  cavities. 

It  is  common  experience  to  find  the  bacillus  in  cadaveric  decompo- 
sition; its  natural  occurrence  in  the  intestine  explains  this  phenomenon. 
Bacillus  aerogenes  capsulatus  has  been  observed  under  a  variety  of 
pathologic  conditions  associated  with  the  formation  of  gas  in  the 
tissues.  It  may  also  induce  septicemia,  in  which  gas  bubbles  are  found 
in  the  blood.  The  presence  of  these  gas  bubbles  in  organs  gives  an  ap- 
pearance which  is  commonly  designated  foamy  organs  (Schaumorgane). 
Gas-bacillus  infection  often  follows  wounds  to  which  dirt  has  gained 
access,  such  as  compound  fractures  and  injuries  of  different  kinds. 
Sometimes,  as  noted  by  Bloodgood,  the  organism  does  not  lead  to  gas 
formation  in  the  involved  or  other  tissues.  Frequently,  however,  it 
induces  emphysematous  gangrene,  most  of  the  cases  involving  the 
extremities.  Gas  may  appear  in  the  tissues  as  early  as  eight  hours 
after  the  injury.  The  lesions  consist  of  necrosis,  gaseous  distention  of 
the  tissues,  infiltration  with  blood,  and  the  exudation  of  serum.  The 
majority  of  the  cases  die  from  the  results  of  general  infection.  On 
the  other  hand,  when  the  disease  is  promptly  and  adequately  treated, 


GANGRENE  51 

recovery  may  occur.  Of  the  cases  collected  by  Welch,  59  per  cent, 
terminated  fatally. 

Gas-bacillus  infection  may  also  occur  in  the  genitourinary  organs, 
especially  in  pregnant  and  puerperal  women  after  abortion.  Gastro- 
intestinal and  other  forms  of  infection  have  been  described. 

Diagnosis. — The  disease  generally  begins  as  any  other  cellulitis. 
It  differs  from  the  ordinary  form  of  cellulitis,  however,  by  its  rapid 
extension,  the  presence  of  a  crackling  sensation  on  pressure,  and  the 
rapid  development  of  grave  septic  symptoms.  The  presence  of  emphy- 
sema in  the  tissues  will,  of  course,  always  excite  suspicion.  It  is 
important  in  such  cases  to  make  cover-slip  preparations  with  material 
from  the  infected  parts.  The  presence  of  rather  large,  straight,  or 
slightly  curved  bacilli,  which  stain  by  Gram,  especially  if  capsulated, 
is  very  suspicious.  This  should  be  further  confirmed  by  introducing 
some  of  the  infected  material  into  the  circulation  of  a  rabbit,  prefer- 
ably into  one  of  the  ear  veins.  After  a  delay  of  about  ten  minutes 
which  is  necessary  to  insure  distribution  of  the  injected  material 
throughout  the  body,  the  animal  should  be  killed  and  placed  in  a 
warm  room  or  incubator.  In  a  few  hours  examination,  if  Bacillus 
aerogenes  capsulatus  be  present,  will  reveal  the  characteristic  appear- 
ance of  "foamy  organs." 

Treatment. — The  treatment  consists  of  free  incisions,  removal  of  the 
gangrenous  cellular  tissue,  and  packing  the  wounds  thus  formed  with 
wet  formalin  gauze  (1  to  50).  Stimulants,  an  abundance  of  nourish- 
ing food,  and  measures  to  favor  rapid  elimination  of  the  toxins  also  are 
indicated. 

GANGRENE. 

The  term  gangrene  is  applied  to  the  process  resulting  in  the  death 
of  tissue  en  masse. 

Etiology. — The  causes  may  be  divided  into:  (1)  Exciting,  which 
consist  of  agents  directly  destroying  the  vitality  of  the  tissues,  or  of 
those  which  act  directly  by  cutting  off  their  nutrient  supply;  and  (2) 
predisposing  causes.  Some  exciting  causes  are  in  themselves  alone  cap- 
able of  causing  gangrene.  For  others,  however,  to  become  operative, 
predisposing  causes  which  impair  the  vitality  of  the  tissues  are  necessary. 
These  are  old  age,  feeble  action  of  the  heart,  chronic  congestion  of  a  part, 
deteriorated  blood,  as  in  diabetes  and  Bright's  disease,  and  the  impair- 
ment or  loss  of  nerve  influence  from  injury  or  disease  of  the  nerve 
centres  or  nerve  trunks.  These  all  may  be  narrowed  down  to  impair- 
ment in  nutrition  of  the  tissues  largely  through  cutting  down  of 
blood  supply  as  in  an  obliterating  endarteritis. 

Of  the  exciting  causes  those  which  act  directly  by  destroying 
the  vitality  of  the  tissues  are:  chemical,  as  strong  acids  or  alkalies: 
bacterial  and  animal  poisons:  mechanical,  as  severe  crushing  of 
a  part;  and  thermal,  as  extremes  of  heat  and  cold  in  burns  and 
frost-bites. 


52  ACUTE  INFECTIOUS  SURGICAL  DISEASES 

Those  causes  which  act  indirectly  by  cutting  off  the  nutrient  supply 
of  tissues  are,  obstruction  to  the  arterial  supply,  as  from  ligature,  em- 
bolism, thrombosis,  arterial  sclerosis;  obstruction  to  the  capillary 
circulation  from  thrombosis  or  pressure,  as  in  bed-sores  or  pressure 
from  a  splint  or  new  growth;  obstruction  to  the  venous  return,  as  in 
strangulated  hernia,  paraphimosis,  tight  bandaging,  etc. 

Clinically,  gangrene  may  be  divided  into  dry  and  moist  forms. 
The  amount  of  fluid  in  the  tissues  at  the  time  gangrene  supervenes 
and  the  degree  of  bacterial  infection  being  the  factors  which  influence 
the  type  of  the  process. 

The  clinical  types  of  gangrene  which  are  usually  dry,  are  senile 
gangrene  from  arterial  scleroses,  embolism,  or  ligature  of  a  main  artery, 
frost-bite,  and  Raynaud's  disease.  The  others,  which  are  often  moist, 
are  inflammatory,  traumatic,  hospital  and  diabetic  gangrene,  phage- 
dena, bed-sores,  carbuncle,  cancrum  oris,  and  noma. 

Symptoms. — In  the  dry  form  of  gangrene  the  onset  and  develop- 
ment are  very  slow.  The  part  first  becomes  pale  and  mottled,  then 
dry,  shrivelled,  and  hard,  turning  to  a  brown  or  black  color  and 
resembling  a  mummy.  As  bacterial  processes  are  not  here  active,  there 
is  no  putrefaction,  and  the  odor,  so  offensive  in  moist  gangrene,  is  absent. 

In  the  moist  form  of  gangrene  the  tissues,  at  the  onset,  are  full  of 
blood  and  fluid,  the  process  is  rapid,  with  little  time  for  the  evapora- 
tion of  fluids,  and  bacterial  activity  is  pronounced  and  often  extreme. 
During  the  early  stages  the  part  becomes  swollen,  dusky  red  in  color, 
edematous,  and  painful.  Later  all  sensibility  is  lost,  it  becomes  colder 
than  natural,  and  the  color  changes  to  a  dark  greenish-purple  tint,  and 
then  becomes  black.  Bloody  bulla?  form  and  the  epidermis  peels  off, 
leaving  a  moist  surface.  Putrefactive  gases  collect  in  the  tissues  and 
cause  crepitation  when  the  part  is  pressed.  The  soft  parts  become 
semisolid  or  liquid,  and  separate  from  the  bone  as  a  slimy,  foul-smelling 
dark  mass. 

As  a  result  of  the  absorption  of  septic  products  the  patient  may 
have  fever,  often  of  the  asthenic  type,  resulting  in  exhaustion  or  death. 

These  two  forms  may  result  in  the  formation  of  a  line  of  demarca- 
tion, or  a  progressive  advance  with  no  definite  limitation. 

In  the  latter  case,  occurring  most  commonly  in  spreading  trau- 
matic gangrene,  the  process  advances  rapidly  up  an  extremity  reaching 
the  trunk,  when  the  patient  falls  into  a  typhoid  condition  and  dies. 
No  line  of  demarcation  forms  and  operative  treatment  consists  of 
amputation,  early  and  far  removed  from  the  injury.  There  is  a  great 
tendency  in  these  cases  for  gangrene  to  occur  in  the  flaps  after  ampu- 
tation. If  the  process  of  gangrene  is  arrested  in  time,  the  so-called  line 
of  demarcation  forms  at  the  junction  of  the  living;  and  dead  tissue; 
and  through  tissue  autolysis,  physical  disintegration  occurs.  This 
gradually  divides  all  the  structures  of  the  part,  skin,  subcutaneous 
tissue,  tendons,  and  vessels. 

Not  alone  autolytic  ferments    but   other   cellular  ferments  from 


GANGRENE  53 

leukocytes  operate  in  the  tissue  liquefaction.  Step  by  step  with  the 
tissue  disintegration,  granulations  form  on  the  living  side  of  the 
line  of  demarcation.  The  entire  process  of  tissue  Liquefaction,  tissue 
growth,  and  separation  is  similar  to  that  which  occurred  in  an  abscess 
cavity.  Therefore  if  the  operative  factors  that  produced  the  gangrene 
are  held  in  abeyance,  repair  may  follow  the  natural  amputation  of  the 
part.  In  the  majority  of  instances,  especially  with  predisposing  fac- 
tors operating,  if  there  is  no  surgical  interference,  a  more  or  less 
stationary  condition  of  the  tissues  develops.  On  the  stump  there  are 
areas  of  granulation  tissue  with  masses  of  dead  tissue  still  attached. 
From  time  to  time  local  infections  occur  leading  often  to  the  death 
of  more  tissue.  Finally  the  individual  is  overcome  by  the  various 
factors  and  dies. 

Treatment. — While  the  details  of  the  treatment  of  gangrene  must 
vary  with  the  type  of  the  process  and  its  cause,  the  following  general 
principles  may  be  adhered  to  in  all  cases: 

(1)  Remove,  where  possible,  the  cause. 

(2)  Combat  threatened  gangrene  by  maintaining  the  warmth  of 
the  part,  improving  the  circulation  by  elevating  the  limb,  and  by 
gentle  friction  where  there  is  venous  congestion. 

(3)  When  gangrene  has  actually  occurred,  check  its  spread  if 
possible;  promote  separation  of  the  dead  from  the  living  part  or 
remove  it  by  amputation;  control,  as  far  as  possible,  the  formation 
of  the  products  of  putrefaction  by  keeping  the  part  dry,  support  the 
patient's  strength,  counteract  the  deleterious  effects  on  the  constitu- 
tion from  the  absorption  of  the  septic  poison,  and  soothe  the  pain  by 
opium. 

Although  the  general  outline  of  symptoms  and  treatment  already 
given  are  applicable  for  most  of  the  forms  of  gangrene,  a  certain  amount 
of  variation  occurs  in  the  various  clinical  forms  of  gangrene  which 
necessitate  brief  mention. 

Clinical  Types. — Senile  Gangrene. — Senile  gangrene,  rarely  occur- 
ring before  sixty  years,  is  usually  caused  by  a  narrowing  of  the  arterial 
lumen  as  a  result  of  advanced  sclerosis  in  connection  with  weak  heart 
action,  the  process  frequently  having  its  origin  in  some  slight  local  injury 
(Figs.  5  and  6).  It  usually  starts  in  the  toes,  and  may  extend  to  the 
ankle  or  knee  before  a  line  of  demarcation  is  formed.  The  gangrenous 
extremity  may  then  be  cast  off  or  the  patient  may  succumb  from 
exhaustion  and  septic  absorption.  The  affected  parts  are  occasionally 
allowed  to  separate  spontaneously.  The  greatest  care  is  employed  to 
cleanse  the  part  and  keep  it  surgically  clean  thereafter.  Dryness  is 
essential,  and  after  an  antiseptic  deodorizing  powrder  is  applied  the 
part  is  wrapped  up  in  a  thick  layer  of  absorbent  gauze. 

Amputation,  if  resorted  to,  is  usually  done  above  the  bifurcation  of 
the  popliteal  artery  to  be  above  the  obstruction  to  the  lumen.  The 
age  and  conditions  of  arteries  and  heart  in  these  patients,  however, 
make  the  conditions  for  operation  far  from  favorable. 


54 


ACUTE  INFECTIOUS  SURGICAL  DISEASES 


Presenile  Gangrene.— While  it  has  long  been  recognized  that  senile 
gangrene  occurs  most  commonly  as  the  result  of  interference  with  the 
nutrition  of  a  part  through  the  diminution  of  the  blood  supply  following 
arteriosclerosis,  it  is  only  recently  that  the  fact  has  been  appreciated 


Fig.  5. — Senile  gangrene  of  foot. 


that  arteriosclerosis  may  occur  in  earlier  life  to  operate  similarly  as  a 
cause  of  this  form  of  gangrene.  This  form  of  gangrene  is  prone  to 
occur  in  Russian  Hebrews  even  below  thirty  years  of  age. 

To  this  process,  occurring  in  the  young,  the  term  presenile  gangrene 
has  been  applied. 


Fig.  6. — Senile  gangrene.    Serial  section  showing  constriction  of  vessel  lumen. 


This  form  of  gangrene,  like  the  senile,  is  apt  to  be  dry,  and,  with 
the  exception  of  the  age  of  the  patient,  differs  in  no  essential  way 
from  the  senile  form,  except  that  the  prodromal  symptoms  may  exist 
for  months  or  years  before  complete  gangrene  finally  occurs  as  a  result 
of  thrombosis  in  the  narrowed  lumen  of  the  affected  vessels. 


GANGRENE 

Ischemic  Gangrene. — In  gangrene  due  to  embolism,  thrombosis,  or  a 
ligature,  the  extent  of  the  process  depends  upon  the  site  of  the  exciting 
cause;  and  the  process  is  usually  of  the  dry  type. 

In  these  eases  it  is  necessary,  before  resorting  to  amputation,  to 
wait  until  an  arrest  of  the  proeess  takes  place.  By  this  means  the 
proper  site  for  amputation  is  best  determined,  and  an  opportunity 
is  given  to  the  collateral  circulation  to  establish  itself  in  the  tissue  which 
is  to  be  used  for  flaps. 

Gangrene  from  frost-bite  is  usually  seen  in  the  fingers,  toes,  ears,  and 
nose.  It  is  usually  typical  of  the  dry  type.  The  treatment  in  the 
early  stage  consists  of  rubbing  the  part  with  snow  or  cold  cloths, 
gradually  making  the  applications  warmer.  Elevation  of  the  part, 
warm,  loose  bandaging,  warmth,  and  general  stimulants  are  then 
employed.  If  gangrene  has  completely  developed,  the  part  may  be 
kept  dry,  dusted  with  an  antiseptic  powder,  and  allowed  to  separate 
at  the  line  of  demarcation,  or  be  removed  by  amputation. 

In  Raynaud'*  disease,  caused  probably  by  some  disturbance  of  the 
vasomotor  nerve  centre  inducing  spasm  of  the  arterioles,  or  in  some 
cases  by  a  peripheral  neuritis,  the  parts,  generally  the  fingers,  become 
first  white,  cold,  and  insensitive,  then  swollen,  red,  dusky  and  painful, 
and  later  black,  the  process,  if  continuing  further,  terminating  in  dry 
gangrene.  Until  the  last  stage  is  reached  relief  may  be  obtained  by  local 
warmth  and  loose  bandaging,  the  constant  descending  electric  current, 
or  placing  the  parts  in  an  electric  bath,  with  the  use  of  general  tonics. 

Ergot  Gangrene. — Ergot  gangrene  occurs  from  tetanic  contraction  of 
the  arterioles,  produced  by  the  contamination  of  rye  bread  with 
claviceps  purpurea.  The  process,  which  attacks  the  fingers,  ears,  or 
nose,  is  preceded  by  formication,  numbness,  and  pains  in  the  parts 
affected.  It  is  advisable  to  wait  for  the  formation  of  a  line  of  demarca- 
tion before  operating  on  these  cases,  and  then  to  amputate  immediately 
above  the  disease. 

Carbolic  Gangrene. — Carbolic  acid,  even  in  comparatively  weak 
solutions  of  2  to  4  per  cent,  is  liable  to  induce  dry  gangrene  when 
applied  as  a  moist  dressing  to  the  fingers  or  toes  for  a  prolonged  period 
of  time  (Fig.  7). 

Before  amputation  is  done  a  distinct  line  of  demarcation  should 
present  itself,  and  in  some  instances  the  dead  tissue  may  be  allowed 
to  separate  naturally  from  the  living,  the  bone  being  then  nipped 
off  high  up  with  forceps. 

Traumatic  Gangrene.  —  Ande  spreading  traumatic  gangrene  is  an 
example  of  moist  gangrene  occurring  in  tissues  which  have  been  badly 
crushed  and  lacerated  and  infected  with  virulent  pathogenic  microbes. 
These  are  often  anaerobic  and  sometimes  gas-producers,  and  include 
the  Bacillus  aerogenes  capsulatus,  Bacillus  of  malignant  edema,  and 
colon  bacillus,  all  of  which  are  capable  of  manufacturing  excessively 
toxic  products.  The  process  is  exceedingly  rapid;  putrefactive  gases 
in  the  tissues  may  give  rise  to  emphysematous  crackling,  and  the 


56 


ACUTE  INFECTIOUS  sih'<;J(AL   blsEAsES 


course  of  the  lymphatics  may  be  traced  by  red  lines  in  the  superficial 
tissues.  The  edges  of  the  wound  are  swollen,  everted;  there  is  a  slight, 
fetid  discharge  of  brownish  serum,  hut  no  pus. 

All  such  wounds  should  be  thoroughly  cleaned,  trimmed  free  of 
tissue  shreds,  the  crevices  well  drained,  exposed  to  air,  and  washed 
with  hydrogen  peroxide. 

(langrene  once  having  developed,  the  patient's  only  hope  lies  in 
immediate  amputation  as  high  as  possible  above  the  gangrenous  part, 
strict  antisepsis  of  the  field  of  amputation  being  maintained.  To 
combat  the  overwhelming  constitutional  effect  of  the  absorbed  poisons 
stimulants  should  be  administered. 


Fig.  7. — Carbolic  acid  gangrene. 


Closely  allied  to  this  form  of  gangrene  is  the  type  known  as  inflam- 
rnatory  gangrene,  or  gangrenous  cellulitis,  occurring  usually  in  the 
subcutaneous  tissue  as  a  result  of  infection  by  the  Streptococcus 
pyogenes.  The  tissues,  which  usually  have  a  low  routing  power  in 
these  cases,  die  as  a  result  of  tension  and  bacterial  poisons.  The  con- 
dition may  progress  rapidly,  and  the  exudate  after  incision  may  be 
serous  without  any  evidence  of  pus. 

Treatment  must  be  prompt  and  energetic,  consisting  of  multiple 
free  incisions  followed  by  copious  antiseptic  irrigations.  Failure  to 
stem  the  advance  of  the  process  by  these  means  must  be  followed  by 


GANGRENE  57 

amputation.  The  constitutional  effect  of  the  absorbed  poisons  is  to 
be  combatted  by  the  use  of  stimulants  and  antistreptococcic  serum. 

Very  closely  allied  to  these  forms  are  cancrum  oris  and  noma,  occur- 
ring as  sloughing  ulcers  in  the  mouth  and  vulva  respectively,  as  a 
result  of  capillary  thrombosis  caused  by  virulent  bacterial  infection 
in  debilitated  patients  after  infectious  diseases.  The  treatment  for 
these  conditions  is  the  same  as  that  of  the  phagedenic  gangrene  just 
described. 

Diabetic  Gangrene. — This  occurs  in  diabetics  as  a  result  of  accom- 
panying endarteritis,  and  lowered  resistance  of  poorly  nourished  tissues 
by  which  the  growth  of  bacterial  organisms  is  aided.  For  this  reason 
diabetic  gangrene,  which  resembles  the  senile  form  in  many  ways,  is 
usually  moist. 

It  usually  starts  in  the  lower  extremity  as  a  result  of  a  slight  wound. 
It  may  spread  rapidly  or  slowly. 

If  the  spread  is  slow,  the  process  should  be  treated  expectantly 
by  local  measures.  If  the  advance  is  rapid,  amputation  at  the  lower 
third  of  the  thigh  should  be  performed. 

In  the  meantime  measures  directed  toward  the  constitutional 
condition  of  diabetes  should  be  employed  with  special  reference  to 
the  avoidance  of  diabetic  coma  following  operation. 

Bed-sores  occur  in  those  whose  tissues  are  partially  devitalized  by 
acute  fevers  and  chronic  diseases.  With  loss  of  sensation  through 
poor  inervation,  continued  pressure  may  lead  to  a  bed-sore.  This  is 
a  frequent  occurrence  in  those  who  have  received  an  injury  to  the 
spinal  cord. 

The  direct  cause  is  usually  pressure  over  a  bony  prominence.  The 
skin  becomes  a  dusky-red  color,  purplish,  and  finally  black.  A  slough 
forms  which  separates,  and  the  process  may  extend  centrifugally  or 
deeply  until  it  reaches  periosteum  or  bone. 

Prevention  of  the  condition  is  most  important  by  the  regular  chang- 
ing of  the  patient's  position,  the  use  of  ring  pads  and  air  cushions, 
thorough  cleanliness,  rubbing  with  alcohol,  drying,  and  the  application 
of  antiseptic  dusting-powders. 

The  ulcers,  once  formed,  are  to  be  treated  by  regular  surgical  methods. 


CHAPTER   IV. 
CHRONIC  INFECTIOUS  SURGICAL  DISEASES. 

TUBERCULOSIS. 

Tuberculosis  is  an  infectious  disease  common  to  man  and  cer- 
tain animals.  It  is  caused  by  Bacillus  tuberculosis,  and  is  character- 
ized by  an  exudative  and  productive  inflammation  in  which  necrosis 
and  caseation  of  the  involved  tissues  commonly  occur.  The  typical 
morphologic  lesions  consist  of  small  nodular  growths  called  tubercles. 

Bacillus  Tuberculosis. — The  contagious  idea  of  phthisis  dates  back 
to  the  time  of  Galen,  who  included  it  among  those  diseases  which 
could  be  communicated  from  one  subject  to  another.  In  the  latter 
half  of  the  fifteenth  century  the  belief  occupied  a  prominent  position 
in  the  minds  of  many  in  Italy,  judging  from  the  sanitary  regulations 
then  in  force  with  reference  to  the  disease.  But  it  remained  for  Villemin 
to  establish  definitely,  by  experimental  studies,  its  infectious  nature. 
His  first  communication  appeared  in  December,  1865.  For  the  dis- 
covery of  the  inciting  agent  we  are  indebted  to  Koch,  whose  announce- 
ment appeared  March  24,  1882. 

The  tubercle  bacillus  does  not  form  spores,  and  grows  best  in  the 
presence  of  oxygen.  Dried  tuberculous  sputum  may  contain  living 
tubercle  bacilli  after  many  months.  The  organism  is  readily  killed 
at  high  temperatures;  its  viability  is  also  affected  by  desiccation, 
putrefaction,  and  particularly  sunlight.  Five  per  cent,  carbolic  acid 
kills  the  organism  in  thirty  seconds;  1  to  1000  solution  of  mercuric 
chloride  in  ten  minutes;  and  absolute  alcohol  in  five  minutes. 

Tuberculosis  has  been  well  studied  experimentally  in  animals. 
Guinea-pigs  are  very  susceptible  to  inoculation  with  cultures  of 
material  containing  tubercle  bacilli.  Variations  in  virulence  have  been 
noted.  Tubercle  bacilli  obtained  from  cold-blooded  animals,  or  from 
cattle,  or  birds  show  cultural  and  pathogenic  differences  from  those  of 
human  derivation. 

Distribution  of  Bacilli. — They  are  present  in  all  tuberculous  lesions, 
although  their  demonstration  may  sometimes  be  very  difficult.  In 
actively  developing  tubercles  they  are  present  in  great  numbers;  but 
in  some  lesions,  such  as  tuberculosis  of  lymph  nodes  and  joints,  they 
are  generally  present  only  in  small  numbers.  Outside  of  the  human 
body  the  organism  is  also  widely  distributed.  This  is  not  surprising 
if  we  recall  the  estimate  of  Nuttall  that  the  twenty-four-hour  sputum 
of    a    consumptive    patient  may  contain  between  300,000,000  and 


TUBERCULOSIS  59 

4,000,000,000  tubercle  bacilli.  In  its  moist  condition  sputum  is  devoid 
of  great  danger,  hut  in  drying  it  is  eventually  converted  into  dust  that 
is  spread  in  all  directions  by  currents  of  air.  Perhaps  nothing  more 
forcibly  emphasizes  the  danger  of  infection  from  such  sources  than  the 
investigation  of  Straus,  who  demonstrated  the  presence  of  bacilli  in 
the  nasal  mucus  of  various  healthy  individuals  frequenting  the  wards 
of  hospitals  in  Paris.  Cornet  showed  that  the  dust  from  the  floors 
and  walls  of  dwellings  in  which  tuberculous  persons  were  living  often 
contained  virulent  tubercle  bacilli;  and  Hance  found  that  the  dust 
of  one  in  five  cars  was  contaminated  with  them.  Baldwin  has  recently 
shown  that  tubercle  bacilli  are  not  uncommonly  present  on  the  hands 
of  tuberculous  patients  who  are  not  careful  in  the  use  of  handkerchiefs, 
clothing,  or  cuspidors*. 

The  Tubercle. — The  local  lesions  induced  by  the  tubercle  bacillus 
are  often  in  the  form  of  circumscribed  nodules,  which  are  called 
tubercles.  Such  localized  tuberculosis  may  remain  as  a  local  inflamma- 
tion; or  by  metastasis  it  may  give  rise  to  the  development  of  tubercles 
in  other  parts  of  the  body.  The  tubercles  are  small  nodular  bodies, 
either  gray  and  translucent,  white  or  yellow,  and  opaque. 

The  action  of  the  tubercle  bacillus  in  the  body  is  twofold;  on 
the  one  hand  it  induces  proliferative  changes  and  leukocytic  emi- 
gration; and,  on  the  other  hand,  it  causes  degenerative  changes 
which  result  in  necrosis.  The  earliest  reaction  consists  in  pro- 
liferation of  the  connective-tissue  cells.  These  become  changed  in 
form  into  the  so-called  epithelioid  cells.  Hand  in  hand  with  these 
changes  new  reticulum  is  formed.  Giant  cells  are  frequently  present. 
Old  bloodvessels  are  usually  obliterated  and  new  ones  are  not  apt  to 
form.  With  the  elaboration  by  the  tubercle  bacilli  of  poisonous 
products  which  act  upon  the  cells,  a  process  of  coagulation  necrosis, 
or  caseation,  develops.  This  begins  in  the  centre  of  the  tubercle, 
gradually  extending  to  the  periphery.  Partial  necrosis  of  giant  cells 
also  is  observed.  The  cheesy  masses  may  undergo  softening,  fibrosis, 
or  calcification.  Under  the  microscope  these  typical  tubercles  usually 
consist  of  small  round  cells,  epithelioid  and  giant  cells,  and  a  reticulum. 
The  caseous  portion  occupies  the  central  part,  perhaps  with  giant  cells. 
Outside  of  this  is  a  zone  of  round  and  epithelioid  cells,  and  bevond 
this  an  area  made  up  almost  entirely  of  small  round  cells.  Instead  of 
such  focal  lesions  as  tubercle,  large  areas  of  tuberculous  inflammation 
may  develop,  showing  more  or  less  caseation  with  an  irregular  sprink- 
ling of  epithelioid  and  round  cells.  But  whatever  the  morphologic 
character  of  the  lesions,  tubercle  bacilli  are  always  present. 

Occurrence  in  Various  Organs.  —  Tuberculosis  may  occur  in  any 
organ,  but  some  tissues  are  more  commonly  affected  than  others. 
Thus  the  lungs,  pleura,  lymph  nodes,  peritoneum,  bones,  joints 
and  testicles  are  more  commonly  involved,  whereas  tuberculosis  of 
the  muscles,  fasciae,  liver,  spleen,  ovaries,  and  pancreas  is  rare.  In 
adults  the  lungs  may  be  regarded  as  the  seat  of  election;  and  in 


00  CHRONIC  INFECTIOUS  SURGICAL  DISEASES 

children  the  lymph  nudes,  bones,  and  joints.  Osier  states  that  in 
1000  autopsies,  275  eases  were  tuberculous,  with  involvement  of  the 
lungs  in  all  but  two  or  three.  The  frequency  of  involvement  of  other 
organs  was  as  follows:  Intestine,  peritoneum,  kidneys,  brain,  spleen, 
liver,  generative  organs,  pericardium,  and  heart.  Surgical  tubercu- 
losis has  a  somewhat  different  distribution.  Of  SS73  patients  of  the 
Wurzburg  clinic,  1287  were  tuberculous,  with  the  following  distri- 
bution: Bones  and  joints,  1037;  lymph  nodes,  196;  skin  and  con- 
nective tissues,  77;  genito-urinary  organs,  20;  mucous  membranes,  10. 

It  is  generally  agreed  that  tuberculosis  is  rare  during  the  first  months 
of  life.    Most  of  the  cases  occur  between  the  ages  of  ten  and  forty. 

Modes  of  Infection. — Certain  well-defined  forms  of  tuberculosis  are 
recognized,  depending  on  the  point  of  entrance  of  the  infectious  agent. 

The  common  primary  localization  of  tubercle  in  the  lungs  indicates 
that  in  a  large  proportion  of  cases  infection  takes  place  by  inhalation. 
The  cases  of  primary  .intestinal  tuberculosis  have  usually  followed 
the  ingestion  of  infected  milk.  Secondary  lesions  in  the  intestines 
are  common,  due  largely  to  the  swallowing  by  consumptive  patients 
of  infected  sputum.  Cases  of  accidental  inoculation  have  been  re- 
ported especially  among  those  working  with  infected  tissues,  such  as 
pathologists,  butchers,  etc.  Congenital  tuberculosis  is  very  rare; 
most  authorities  concede  that  the  tubercle  bacilli  are  transmitted  only 
occasionally  from  parent  to  offspring. 

Predisposing  Factors. — There  is  general  agreement  that  under 
certain  conditions  leading  to  extreme  impurity  of  the  air  tuberculosis 
becomes  frequent.  Absence  of  sunlight  and  ventilation  are  important 
predisposing  factors.  Formerly  accorded  a  most  important  role, 
inherited  predisposition  has  been  less  insisted  upon  within  recent  years. 
Those  who  follow  certain  occupations  have  been  shown  to  contract 
the  disease  more  readily  than  others.  The  influence  of  sex  is  very 
slight. 

It  is  generally  claimed  that  an  intimate  association  exists  in  many 
cases  between  trauma  and  the  subsequent  development  of  a  tubercu- 
lous lesion  in  or  about  the  injured  part.  It  is  of  interest  to  point  out 
that  the  occurrence  of  tuberculosis  at  the  site  of  a  simple  fracture  is  a 
surgical  curiosity.  Simple  fractures  are  of  common  occurrence  in  those 
obviously  tuberculous  as  well  as  those  free  of  the  disease.  The  above 
seems  to  contradict  the  statement  that  injury  as  such  is  a  predisposing 
factor  as  regards  the  location  of  the  infection.  In  some  cases,  on  the 
other  hand,  generalized  tuberculosis  has  followed  injury  to  tissue  in 
which  there  was  only  local  tuberculosis. 

Bacteriologic  Diagnosis. — Bacteriologic  examination  always  con- 
stitutes one  of  the  most  important  features  in  the  diagnosis  of  any 
case  of  tuberculosis. 

Examination  of  Sputum. — Preferably  the  morning  sputum  is  col- 
lected. The  fine,  cheesy  particles  should  be  carefully  selected,  as  they 
are  more  apt  to  contain  the  tubercle  bacilli. 


SYPHILIS  61 

Examination  of  Urine — In  cases  of  suspected  genitourinary 
tuberculosis  the  urine  should  be  obtained  by  sterile  catheterization, 
centrifuged,  and  the  sediment  collected.  It  is  usually  very  difficult 
to  find  tubercle  bacilli  in  urinary  sediments.  Moreover,  unless  special 
precautions  are  taken,  the  smegma  bacillus,  which  is  normally  present 
about  the  external  genitals,  and  has  tinctorial  reactions  similar  to  the 
tubercle  bacillus,  may  be  mistaken  for  it.  The  safest  way  is  to  have 
recourse  to  guinea-pig  inoculations,  either  intraperitoneal  or  subcu- 
taneous. 

Examination  of  Serous  Exudates. — The  search  for  tubercle  bacilli 
in  the  exudates  of  tuberculous  pleurisy,  peritonitis,  meningitis,  or 
arthritis  is  often  uncertain  and  tedious.  The  exudates  are  to  be  re- 
moved with  bacteriologic  precautions  and  collected  in  sterile  recep- 
tacles. Fluid  may  be  obtained  from  cases  of  meningitis  by  lumbar 
puncture.  For  microscopic  examination  it  is  important  to  centrifugate 
the  fluid  because  the  tubercle  bacilli  are  almost  always  present  in  small 
numbers.    Guinea-pig  inoculation  is  the  best  test. 

Biological  Diagnosis. — Von  Pirquet  has  suggested  a  serum  test  which 
when  negative  is  of  extreme  value  but  when  positive  affords  little 
assistance  to  the  surgeon  in  deciding  upon  the  diagnosis  of  any  par- 
ticular lesion.  This  is  because  of  the  extreme  sensitiveness  of  the  test 
and  the  frequency  of  tuberculosis  which  always  results  in  a  positive 
reaction. 

SYPHILIS. 

Syphilis  is  a  specific  constitutional  disease  limited  to  man,  the  virus 
of  which  may  be  transmitted  by  inoculation  to  some  of  the  lower 
animals.  Acquired  syphilis  and  congenital  syphilis  are  spoken  of, 
depending  upon  whether  the  disease  was  acquired  before  or  after 
birth.  There  is  but  little  question  that  the  organism  dies  promptly 
away  from  living  animal  tissues  unless  kept  moist  and  warm.  There- 
fore very  direct  contact  with  an  infectious  individual  is  practically 
essential  for  inoculation  to  occur.  If  during  pregnancy  the  mother 
is  infectious  the  fetus  rarely  escapes  acquiring  the  disease.  Similarly 
during  life  an  individual  rarely  escapes  infection  if  his  or  her  injured 
tissues  come  in  contact  with  a  syphilitic  lesion  in  an  infectious  stage. 
Syphilis  is  acquired  by  contact  with  objects,  drinking  cups,  dentists' 
tools,  etc.,  very  recently  contaminated  and  on  which  the  Spirochete 
pallida  chances  to  survive.     Such  infections,  however,  are  rarities. 

Etiology. — The    disease    prevails    throughout    the    civilized    world. 

Until  recently  the  cause  of  this  disease  was  unknown;  but  in  1905 
Schaudinn  and  Hoffman  discovered  a  slender  spiral  organism,  the 
Spirochete  pallida,  which  has  been  found  in  syphilitic  lesions  and  in 
these  only,  and  which  has  been  obtained  from  the  scrapings  of  chancres, 
enlarged  glands,  mucous  patches,  and  flat  condylomata  in  syphilitic 
cases,  and  may  be  readily  demonstrated  in  these  scrapings,  and  occa- 
sionally in  scrapings  from  tertiary  lesions  by  means  of  the  Giemsa 


62  CHRONIC  INFECTIOUS  SURGICAL  DISEASES 

stains.  To  demonstrate  the  organism  in  tissues  the  method  of  Livaditi 
is  usually  employed. 

The  Spirochete  pallida  varies  in  length  from  4  to  14,u,  has  from 
three  to  twelve  curves,  and  pointed  ends. 

The  virus  gains  entrance  to  the  body  by  contact  with  some  abraded 
surface.  As  in  the  great  majority  of  instances  this  occurs  on  the  genital 
organs  during  sexual  intercourse,  the  disease  has  been  generally 
regarded  as  a  venereal  affection.  It  must  be  "remembered,  however, 
that  inoculation  may  occur  at  any  point  and  in  a  great  variety  of  ways, 
and  many  examples  of  non-venereal  infection  are  observed. 

Acquired  Syphilis. — Symptoms. — Primary  Period. — The  seat  of  in- 
oculation, after  a  certain  period  of  incubation  varying  from  one  to  six 
weeks,  presents  certain  characteristic  tissue  changes  resulting  in  the 
formation  of  the  chancre  or  initial  lesion.  This,  in  the  majority  of 
instances,  is  an  elevated  indurated  nodule,  presenting  on  its  surface 
an  area  of  indolent  ulceration.  The  lesion  is,  as  a  rule,  single  and 
painless,  and  is  often  discovered  by  accident.  In  women  the  initial 
lesion  is  often  overlooked.  As  the  chancre  develops  the  anatomically 
related  lymph  nodes  show  a  gradual  and  painless  enlargement.  In 
initial  lesions  occurring  within  the  mouth,  this  glandular  enlargement 
is  often  the  first  symptom  of  the  disease  which  attracts  attention. 

Secondary  Period. — After  development  of  the  chancre  and  enlarge- 
ment of  the  neighboring  lymph  nodes,  there  is  a  second  period  of 
incubation,  during  which  no  further  manifestations  of  the  disease  ap- 
pear. The  length  of  this  period  varies  from  two  weeks  to  six  months, 
the  average  being  about  four  or  five  weeks.  At  the  end  of  this  period 
the  so-called  secondary  symptoms  appear.  These  are  a  general  feeling 
of  malaise,  fever,  headache,  and  pains  in  the  long  bones,  especially 
those  of  the  lower  leg.  The  pharynx  is  congested  and  sore;  there 
appears  a  faint  generalized  eruption,  more  marked  on  the  chest  and 
abdomen,  which  may  be  simply  a  slight  hyperemia  of  the  skin,  or  it 
may  take  the  form  of  irregular  macules  without  elevation  or  induration 
— syphilitic  roseola  or  macular  syphilids.  With  this  there  is  a  painless 
enlargement  of  the  lymph-nodes  throughout  the  entire  body.  These 
are  appreciated  best  in  the  cervical  region,  both  the  anterior  and  pos- 
terior chains,  in  the  epitrochlear  regions,  in  the  axilhe  and  groins. 
As  the  initial  eruption  fades  other  cutaneous  lesions  appear,  generally 
in  the  form  of  papules — papular  syj>hilide.  These,  as  a  rule,  are 
small  elevated  nodules  of  a  brownish-red  or  copper  color,  and  are 
distinctly  indurated.  They  appear  first  on  the  abdomen,  chest,  and 
back;  later  on  the  arms  and  thighs;  at  a  still  later  period  on  the 
forearms,  face,  and  legs;  and  finally,  on  the  palms  and  soles.  With 
these  early  secondary  cutaneous  lesions  there  is  often  an  increase  in 
the  headache  and  malaise;  the  mucous  membrane  of  the  mouth  and 
pharynx  presents  superficial  ulcerative  lesions  or  mucous  patches, 
which  are  most  frequently  located  on  the  lips  and  cheeks,  near  the 
angles  of  the  mouth,  on  the  sides  of  the  tongue,  on  the  tonsils  and 


SYPHILIS 


63 


pharynx.  There  is  an  increased  flow  of  saliva,  the  mouth  is  sore,  and 
swallowing  may  be  painful.  Scabs  appear  on  the  scalp,  the  hair  falls 
out,  the  eyebrows  and  beard  may  become  markedly  thin,  and  in  places 
complete  alopecia  may  be  present.  These  symptoms  persist  for  a 
variable  period  in  untreated  cases,  but  they  may  disappear  spontan- 
eously in  a  short  time.  In  certain  cases  the  symptoms  are  so  mild  as 
to  be  overlooked.  At  a  later  period  recurrent  eruptions  appear  on  the 
skin,  generally  less  symmetric,  and  often  limited  to  small  areas.  These 
may  be  papular  (large  and  small),  pustular,  squamous,  or  pustulocriis- 
taceous.  In  certain  moist  localities,  as  about  the  anus,  in  the  axilhe, 
or  beneath  a  pendulous  breast,  large  flat  raw  lesions  may  appear, 


\   J 

c    i?  '*         ^H 

^^^apP^^         ^B 

W^      V 

i^^pm*^*" 

■ 

.    * 

r^L                 -Jr^ 

w 

Fig.  8. — Chancre  of  the  penis. 


which  furnish  an  acrid  secretion.  These  are  spoken  of  as  condylomata 
or  mucous  tubercles.  Papillomata  may  also  appear  in  these  situations, 
but  are  not  to  be  regarded  as  truly  syphilitic  lesions,  as  they  occur 
under  other  conditions. 

If  the  patient  has  been  under  intelligent  treatment  during  the  first 
two  years  after  his  inoculation,  the  symptoms  of  the  disease  gradually 
disappear,  and  he  may  be  completely  restored  to  health. 

Tertiary  Period. — In  a  fair  number  of  cases,  however,  chiefly  those 
who  have  not  been  subjected  to  continuous  treatment  for  two 
years,  lesions  appear  later  in  life  which  are  called  gummata.  These 
consist  of  masses  of  round  and  epithelioid  cells,  often  forming  large 


04 


CHRONIC  INFECTIOUS  SURGICAL  DISEASES 


tumors  which  present  a  gray  or  yellowish  color,  are  poorly  nourished, 
and  are  prone  to  break  down  and  present  caseous  or  necrotic  changes. 
These  lesions  may  occur  in  any  organ  or  tissue  of  the  body  and  give 
rise  to  a  variety  of  symptoms.  When  they  occur  in  the  skin  they  pre- 
sent lesions  spoken  of  as  tubercular,  pustulocrustaceous,  rupial,  ulcera- 
tive, and  serpiginous  syphilides.    In  the  subcutaneous  tissues  they  give 


Fig.  9. — Gumma  of  the  knee. 


rise  to  gummatous  ulcerations.  On  the  mucous  membranes,  especially 
that  of  the  pharynx,  gummata  grow  rapidly  and  painlessly,  ulcerate, 
and  cause  great  losses  of  tissue  in  a  comparatively  short  period  of 
time. 

The  syphilitic  virus  also  produces  marked  changes  in  the  blood- 
vessels, which  are  observed  chiefly  in  the  smaller  arteries,  and  result 


SYPHILIS  65 

in  a  slowly  progressive  narrowing  of  their  lumen,  syphilitic  endarteritis. 
This,  by  diminishing  the  blood  supply  to  a  part,  results  in  various 
degenerative  changes,  which  occur  most  frequently  in  the  tertiary 
period  of  the  disease,  and  give  rise  to  a  variety  of  lesions,  chief  among 
which  may  be  mentioned  aneurism,  cerebral  hemorrhage,  thrombosis, 
chronic  interstitial  changes  in  certain  organs,  and  interference  with  the 
blood-making  function.  Locomotor  ataxia,  paresis,  and  other  disturb- 
ances of  the  central  nervous  system  are  regarded  by  most  authorities 
as  late  effects  of  the  syphilitic  poison,  and  are  spoken  of  as  para- 
syphilitic  affections.  The  tertiary  syphilitic  manifestations  in  the 
different  organs  of  the  body  will  be  described  later. 

Diagnosis. — The  diagnosis  of  syphilis,  in  the  great  majority  of 
instances,  is  easily  made  from  the  history  and  the  results  of  a  careful 
physical  examination.  In  certain  rare  instances  great  difficulty  may 
be  encountered.  In  these  cases  the  demonstration  of  the  spirochete  in 
the  lesions  is  of  great  value.  The  Wassermann  blood  reaction  is  of 
essential  service  in  making  a  diagnosis  or  rather  establishing  whether 
or  not  the  individual  is  a  syphilitic. 

Treatment. — Until  the  diagnosis  is  established,  no  treatment  other 
than  that  addressed  to  the  initial  lesion  should  be  given.  The  habit 
of  giving  mercury  in  doubtful  cases  to  prevent  the  possible  appearance 
of  cutaneous  and  other  lesions  is  to  be  condemned,  as  it  may  prevent 
the  possibility  of  ever  arriving  at  a  correct  diagnosis,  and  renders  the 
life  of  the  individual  miserable  from  doubt  and  syphilophobia. 

In  the  early  or  secondary  stage  of  the  disease  the  chief  reliance 
must  be  placed  on  the  judicious  administration  of  mercury  and  the 
arsenical  preparation  salvarsan  or  "  606,"  formulated  by  Ehrlich.  Sal- 
varsan  may  be  used  in  several  intravenous  injections  but  must  be 
followed  by  the  old  time  mercury,  potassium  iodide  treatment.  Neo- 
salvarsan  a  subsequent  preparation  of  arsenic  is  also  used  intravenously 
with  success.  After  one  or  more  injections  of  salvarsan  have  been 
administered  and  a  negative  Wassermann  obtained,  it  is  desirable  to 
employ  mercury  in  some  form.  This  may  be  accomplished  by  the 
internal,  the  external,  or  by  the  subcutaneous  use  of  the  drug. 

Internally  the  protiodide  of  mercury,  preferably  combined  with 
iron  to  combat  the  always  present  syphilitic  anemia,  is  the  most 
useful  form  of  drug.  At  first  from  1  to  2  grains  of  the  drug  should  be 
administered  daily  in  divided  doses,  taken  immediately  after  meals. 
As  soon  as  the  effects  of  the  drug  are  noticeable,  the  dose  should  be 
diminished  and  kept  at  a  point  where  the  symptoms  are  controlled 
without  producing  salivation,  diarrhea,  or  other  unpleasant  effects. 
The  amount  of  mercury  necessary  to  control  the  symptoms  of  the 
disease  is  exceedingly  variable.  Some  patients  will  keep  free  from 
symptoms  by  \  grain  daily,  while  others  require  from  2  to  3  grains. 
When  the  dose  is  finally  adjusted  to  the  needs  of  the  patient,  it  should 
be  continued  for  two  years.  After  this  the  treatment  should  be  taken 
every  second  month  for  six  months,  after  which  a  period  of  observation 
5 


66  CHRONIC  INFECTIOUS  SURGICAL  DISEASES 

for  six  months  should  be  insisted  upon  without  treatment,  at  the  end 
of  which,  if  the  patient  has  remained  free  from  all  symptoms  of  the 
disease,  he  may  be  pronounced  well.  On  account  of  the  ease  of  admin- 
istration of  mercury  in  this  form,  this  will  probably  remain  the  most 
popular  method  of  treatment  for  syphilis,  in  spite  of  the  fact  that  the 
methods  of  inunction  and  injection  are  less  liable  to  disturb  digestion. 
Mercury  may  also  be  administered  by  the  inunction  of  mercurial  oint- 
ment (30-60  grains  once  daily),  by  the  vapor  bath,  or  by  means  of 
hypodermic  injections.  If  the  inunction  method  be  employed,  the 
ointment  should  be  rubbed  in  the  non-hairy  portion  of  the  skin,  and 
a  new  location  should  be  chosen  each  day  until  all  of  the  available 
skin  has  been  covered.  The  inunction  method  is  considered  by  many 
more  efficacious  than  the  method  of  ingestion,  but  is  less  popular  on 
account  of  the  disagreeable  features  attending  its  application. 

Hypodermic  or  intramuscular  injection,  while  at  all  times  slightly 
painful,  is  one  of  the  surest,  swiftest,  and  safest  methods  of  treatment 
of  syphilis.  The  salt  of  mercury  most  generally  employed  in  this  way 
is  the  salicylate,  which  is  used  in  the  following  form. 

Salicylate  of  mercury,  3     (gr.  xlviij) 

Alboline  or  oil  of  vaseline,  30  I  (5J) 

Inject  5  to  10  cgm.  (9  to  16  minims)  once  or  twice  a  week. 

Fournier  expresses  a  preference  for  "gray  oil"  of  the  following 
composition : 

Purified  mercury,  •  20  parts 

Vaseline,  10  parts 

Oil  of  vaseline,  20  parts 

Dose.- — Three  drops  at  first,  the  dosage  being  increased  up  to  seven,  eight,  or  ten 
drops  once  a  week. 

For  the  tertiary  gummatous  lesions  the  treatment  should  be  salvar- 
san,  mercury,  and  potassium  iodide,  the  two  former  to  combat  any 
virus  which  may  still  remain  in  the  body,  the  latter  to  promote  absorp- 
tion of  the  gummatous  material.  These  latter  drugs  may  be  given  in 
combination  by  the  "mixed  treatment"  or  separately,  mercury  being 
given  until  the  constitutional  effects  or  the  drugs  are  beginning  to  be 
manifest,  followed  by  potassium  iodide  in  doses  ranging  from  5  to  100 
grains  three  times  a  day.  Treatment  has  no  effect  on  the  vascular 
lesions  of  the  disease  or  the  degenerative  changes  which  result  from 
them.  The  parasyphilitic  lesions  of  the  central  nervous  system  are 
often  much  benefited  and  improved  by  salvarsan. 

Congenital  Syphilis. — A  child  may  acquire  syphilis  from  the  mother 
before  birth,  and  authorities  hold  that  the  mother  of  a  syphilitic  child 
is  always  syphilitic.  It  is  generally  recognized  that  mothers  are 
immune  to  a  secondary  infection,  as  evidenced  by  the  fact  spoken  of 
as  Colles'  law,  that  a  nursing  mother  never  acquires  a  nipple  chancre 
from  her  syphilitic  offspring. 

Pregnancy  occurring  in  a  woman  during  the  early  secondary  stage 


SYPHILIS 


67 


of  an  untreated  syphilis  generally  results  in  abortion.  If  the  woman 
is  well  under  the  influence  of  treatment,  or  if  conception  occurs 
at  a  later  period,  premature  birth  of  a  dead  fetus  is  to  be  ex- 
pected. If  the  virulence  of  her  infection  is  reduced  still  further  by 
treatment  or  time,  a  living  child  will  be  born  presenting  unmis- 
takable signs  of  congenital  syphilis.  If  the  virus  is  attenuated  still 
further,  an  apparently  healthy  child  may  be  born,  which  may  later 
in  life  present  the  evidences  of  syphilis,  or  the  child  may  be  free  from 
disease.  It  is  exceedingly  rare  for  a  syphilitic  child  to  be  born  of  a 
syphilitic  mother  who  has  been  under  mercurial  treatment  for  two  or 
more  years,  or  of  a  mother  four  years  after  the  date  of  her  inoculation 


Fig.  10. — Craniotabes  of  syphilitic  origin. 

with  or  without  treatment.  Parents  frequently  beget  healthy  children 
while  they  still  present  on  their  bodies  the  evidences  of  tertiary  syphilis. 
It  is  probably  impossible  for  a  syphilitic  father  to  transmit  syphilis  to 
his  child  through  a  healthy  mother. 

Symptoms. — With  the  exception  of  the  initial  lesion,  all  of  the 
symptoms  of  acquired  syphilis  may  occur  in  the  congenital  form  of 
the  disease.  Syphilitic  children  are  generally  premature,  are  small, 
puny,  and  often  deformed.  The  face  is  pinched  and  the  skin  wrinkled, 
giving  the  appearance  spoken  of  as  the  "old-man  countenance."  A 
macular  eruption  is  frequently  present  at  birth  over  the  trunk,  and 
mucous  patches  frequently  are  found  about  the  mouth  and  anus. 
The  child  is  irritable,  suffers  from  snuffles  and  digestive  disturbances, 


68  CHRONIC  INFECTIOUS  SURGICAL  DISEASES 

and  rarely  thrives.  Visceral  lesions  may  develop,  generally  gummatous 
in  character,  and  early  death  is  the  rule. 

If  the  infection  is  less  virulent,  the  appearance  of  the  child  at  birth 
may  be  normal;  digestive  and  nutritive  disturbances,  however,  occur; 
and  as  the  child  grows,  symptoms  of  rickets,  bone,  and  joint  disease 
develop,  with  keratitis,  cutaneous  lesions,  and  glandular  enlargements. 
The  two  upper  central  incisors  of  the  permanent  teeth  are  often  notched 
and  narrowed  (Hutchinson  teeth),  and  other  deformities  of  the 
bony  skeleton  may  be  present,  as  a  thinning  of  the  bones  of  the  skull 
(craniotabes)  (Fig.  10)  and  enlargement  of  the  epiphyses  (syphilitic 
osteochondritis). 

Treatment. — Congenital  syphilis  is  treated  best  by  the  application 
of  mercurial  ointment,  half  strength,  or  of  the  oleate  of  mercury,  5 
per  cent.,  to  the  body  of  the  child  by  means  of  a  flannel  bandage, 
which  should  be  worn  each  night.  Good  food,  tonics,  iron,  and  cod-liver 
oil  are  useful  at  a  later  period. 


ACTINOMYCOSIS. 

Actinomycosis  is  a  chronic,  infectious  disease,  common  to  man  and 
many  of  the  domestic  animals,  caused  by  Streptothri.v  actinomyces,  or 
the  ray  fungus. 

Etiology. — Actinomycosis  is  a  widespread  infection  among  cattle, 
in  which  it  is  known  chiefly  as  "lumpy  jaw."  The  organism  probably 
belongs  to  the  streptothrix  group  of  bacteria.  In  the  infected  tissue, 
the  contents  of  abscess-cavities,  and  the  discharge  from  fistulous  tracts 
the  actinomyces  may  be  found  in  the  form  of  small  yellowish,  more 
or  less  opaque  granules,  varying  in  size  from  0.15  to  0.75  mm.,  although 
larger  granules  often  are  seen.  In  their  earliest  stage  the  granules  are 
usually  grayish  white  and  are  easily  broken  up,  the  consistency  being 
that  of  a  soft  jelly.  As  the  granule  grows  older,  it  becomes  more  opaque 
and  yellow,  and  finally  it  may  become  impregnated  with  calcium  salts. 
In  the  earlier  stages  the  granules  are  made  up  of  fine  threads,  which 
later  become  thicker,  and  at  their  ends  present  bulbous  swellings. 
Gradually  the  threads  become  more  compact  and  intricate  in  their 
arrangement,  and  the  bulbous  swellings  become  arranged  radially 
about  the  periphery  of  the  granule.  The  mycelium  usually  appears 
as  a  bacillus  from  3  to  6^  in  length,  arranged  in  threads  having  many 
branches.  The  actinomyces  stain  readily  with  the  ordinary  basic 
anilin  dyes.  They  are  not  decolorized  by  Gram's  method.  The  bulbous 
swellings,  on  the  other  hand,  stain  only  with  acid  dyes.  The  organism 
is  a  facultative  anaerobe  and  grows  upon  most  of  the  artificial  media. 
The  most  favorable  temperature  for  its  growth  is  from  33°  to  37°  C. 
It  is  conceded  that  spore-formation  occurs,  the  spores  being  much 
more  resistant  to  injurious  agents  than  is  the  mycelium.  The  actino- 
myces do  not  appear  to  manufacture  any  active  toxin.    Attempts  at 


ACTINOMYCOSIS  69 

artificial  production  of  the  disease  have  not  been  satisfactory.  The 
great  carriers  of  the  actinomycotic  excitant  are  the  different  forms 
of  cereal,  especially  barley,  and  it  is  mainly  through  their  agency 
that  man  and  the  domestic  animals  become  infected.  Men  are  infected 
more  frequently  than  women.  Of  357  cases  of  human  actinomycosis 
collected  by  Hutyra,  one-third  occurred  in  the  third  decade.  Four 
chief  avenues  of  infection  have  been  distinguished:  First,  through 
the  mouth  and  pharynx,  particularly  carious  teeth;  second,  through 
the  respiratory  tract;  third,  through  the  gastro-intestinal  tract; 
fourth,  through  the  skin,  wounds,  etc.  In  a  certain  number  of  cases 
no  portal  of  entry  can  be  made  out. 

Pathologic  Anatomy. — The  lesions  at  the  outset  may  be  insignificant. 
Microscopic  examination  of  an  actinomycotic  focus  shows  a  central 
portion  containing  the  fungus.  In  addition  there  are  more  or  less 
debris  and  products  of  degeneration.  Around  this  portion  is  a  zone  of 
small,  round,  and  epithelioid  cells.  The  outermost  portions  of  the 
actinomycotic  focus  are  characterized  by  more  or  less  extensive 
round-cell  infiltration.  Giant  cells  are  sometimes  present.  The  pro- 
liferation of  cells  may  become  so  extensive  that  a  definite  tumor-like 
mass  is  produced.  Suppuration  sometimes  occurs.  The  tendency  to 
the  formation  of  fistulous  tracts  is  characteristic,  the  discharge  from 
these  fistulse  sometimes  being  serous,  sometimes  purulent.  The  dis- 
charged material  usually  contains  the  actinomycotic  granules.  The 
lesions  extend  rather  by  continuity  than  by  metastases.  Poncet  and 
Berard  proposed  the  following  division  of  actinomycotic  infections: 
First,  cervicofacial;  second,  thoracic;  third,  abdominal;  fourth, 
cutaneous.  Foci  in  the  spinal  column,  genito-urinary  tract,  brain, 
special  organs  of  sense,  etc.,  are  regarded  as  complications.  Statistics 
show  that  about  55  per  cent,  of  the  cases  belong  to  the  first  group; 
about  20  per  cent,  to  the  thoracic  and  pulmonary  group;  and  about 
20  per  cent,  to  the  abdominal  type;  5  per  cent,  covering  the  remaining 
forms.  It  is  stated  that  lymph  nodes  do  not  become  involved  except 
by  local  extension  through  the  tissues.  This  suggests  that  the  parasite 
is  carried  by  the  blood  stream  rather  than  lymph  vessels. 

Symptoms. — Actinomycosis,  with  rare  exceptions,  is  a  chronic  disease, 
lasting  for  months  or  years.    Four  clinical  forms  are  described: 

Face  and  Neck. — The  initial  lesion  often  begins  around  a  carious 
tooth.  The  patient  comes  under  observation  with  a  swelling  of 
one  side  of  the  face  or  with  an  enlargement  of  the  jaw,  which  may 
simulate  sarcoma  (Fig.  11).  The  lesion  is  seen  best  on  the  outer  side 
of  the  jaw  in  the  form  of  a  swelling,  with  one  or  more  fistulous  tracts 
discharging  material  which  often  contains  the  characteristic  sulphur- 
like granules.  In  the  chronic  forms  pain  is  not  frequently  com- 
plained of,  except  perhaps  on  pressure.  Fever  is  generally  absent  and 
the  general  health  remains  satisfactory.  If  not  checked,  the  process 
may  extend  to  the  neck,  along  the  pharynx,  and  finally  involve  the 
vertebrae  or  the  thoracic  organs  (Fig.  12).     Amyloid  degeneration  of 


70  CHRONIC  INFECTIOUS  SURGICAL  DISEASES 

the  viscera  is  sometimes  seen.  In  the  acute  forms  fever  is  present  and 
the  symptoms  are  those  of  phlegmon.  The  tongue  is  rarely  involved. 
Thorax. — Involvement  of  the  thoracic  organs  is  generally  secondary 
to  lesions  on  the  face  and  neck,  but  the  lungs  may  be  the  primary 
seat  of  the  infection.  In  this  form  we  have  a  chronic  infectious  disease 
of  the  lungs— cough,  fever,  emaciation,  and  mucopurulent  discharge. 
Hodenpyl  recognized  three  types:  First,  lesions  of  chronic  bronchitis; 
second,  miliary  actinomyces,  the  lesions  of  which  closely  resemble 


A 

Fig.  11. — Actinomycosis  of  the  cheek.     (Ulich.) 

those  of  miliary  tuberculosis;  third,  cases  in  which  we  have  broncho- 
pneumonia, interstitial  changes,  and  abscess  formation.  Clinically 
the  disease  resembles  certain  forms  of  pulmonary  tuberculosis.  The 
diagnosis  is  made  by  finding  the  actinomyces. 

Abdominal  Organs. — In  this  form  the  gastro-intestinal  tract  is 
primarily  involved.  There  is  no  organism  which  may  cause  so  exten- 
sive destruction  of  the  abdominal  viscera  as  actinomyces.  Adhesions 
and  abscesses  are  conspicuous  features  of  the  lesions. 

The  actinomyces  gain  access  to  the  stomach  with  food,  either 


ACTINOMYCOSIS  71 

animal  or  vegetable,  most  commonly  the  latter.  Neither  the  gastric 
juice  nor  the  bile  appears  to  have  any  very  decidedly  harmful  effect 
upon  the  fungus.  Once  having  penetrated  the  mucosa,  two  modes 
of  progression  are  possible:  first,  a  superficial  involvement  of  the 
mucosa;  second,  a  penetration  into  the  deeper  structures  without 
leaving  behind  any  demonstrable  defect  in  the  mucosa. 

Intestinal  actinomycosis  usually  appears  first  as  a  small  nodule 
in  the  submucosa,  wrhich  undergoes  degeneration  at  its  centre  and 
presently  gives  rise  to  a  small  ulcer.  In  certain  instances  the  ulcers 
heal,  leaving  irregular  pigmented  scars. 

Among  the  secondary  lesions  of  abdominal  actinomycosis  those 
of  the  liver  are  the  most  frequent.  From  50  to  60  per  cent,  of  the 
abdominal  cases  originate  in  the  cecum  and  appendix;  less  frequently 
the  disease  starts  in  the  rectum,  stomach,  or  small  intestine. 


Fig.  12. — Actinomycosis  of  the  neck.     (Lexer.) 

In  many  cases  the  onset  is  quite  sudden — catarrhal  disturbance 
of  the  intestine,  diarrhea,  vomiting,  or  constipation.  In  other  cases 
the  symptoms  simulate  those  of  recurring  appendicitis.  The  initial 
symptoms  may  last  for  weeks  or  months.  The  second  period  of  the 
disease  is  characterized  by  tumor  formation,  which  is  generally  in 
the  right  iliac  or  umbilical  region.  The  tumor  outline  is  usually  in- 
definite and  irregular.  Pain  is  common.  Later,  softening  of  the  in- 
filtrated portions  takes  place,  leading  to  fistulous  formation,  and  the 
surrounding  skin  assumes  a  bluish-violet  tint,  which  changes  to  a 
slate  color  from  centre  toward  the  periphery.  According  to  some 
observers  this  appearance  is  sufficiently  characteristic  to  excite  sus- 
picion of  actinomycosis.  Spontaneous  recovery  is  possible.  The  prog- 
nosis is  variable;  it  is  the  best  in  those  cases  which  are  amenable  to 


72 


CHRONIC  INFECTIOUS  SURGICAL   DISEASES 


surgical  treatment,  and  it  is  for  this  reason  that  the  prognosis  is  more 
favorable  in  abdominal  than  in  thoracic  cases. 

Skin  and  Brain. — Actinomycosis  of  these  tissues  is  rare.  In  the 
skin  the  lesion  simulates  tuberculosis.  The  cerebral  lesions  are  gen- 
erally postmortem  findings. 

Treatment. — This  is  largely  surgical.  If  the  foci  of  infection  can 
be  completely  removed,  recovery  may  be  expected.  In  the  majority 
of  instances  this  is  not  possible,  and  partial  removal  with  the  admin- 
istration of  large  doses  of  potassium  iodide,  or  the  salts  of  copper,  con- 
stitutes the  best  treatment.  The  various  forms  of  radiant  energy  may 
be  employed. 


Fig.  13.— 


BLASTOMYCOSIS. 

Blastomycosis  {Oidiomycosis)  is  a  localized  inflammation  affecting 
the  skin  (blastomycetic  dermatitis)  and  deeper  tissues,  which  is  caused 
by  the  parasite  yeast  organisms,  Blastomycetes  or  Oidii.  These  occur 
as  rounded,  double-contoured  bodies  measuring  10  to  2(V  in  diameter, 
which  reproduce  by  budding  and  contain  various  rounded,  refractile 
or  granular  structures  (Fig.  13).  They  are  found  in  the  diseased  tissues 
and  frequently  within  giant  cells;  are  readily  cultivated  on  artificial 
media,  and  can  be  successfully  inoculated  into  animals. 

Clinically  the  disease  may  be  confused  with  syphilis,  lupus  vulgaris, 
lupus  verrucosus,  or  epithelioma.  The  diagnosis  may  always  be  made 
by  microscopic  examination  of  smears  and  tissue. 


BLASTOMYCOSIS  73 

The  process  is  found  most  commonly  on  the  skin  of  the  hands  and 
face,  particularly  about  the  orbit.  Though  generally  local,  generaliza- 
tion may  take  place,  causing  involvement  of  the  lungs,  hones,  muscles, 
spleen,  or  kidneys.  Though  the  skin  is  usually  the  scat  of  the  primary 
infection,  the  viscera  may  be  the  structures  first  involved. 

Clinically  the  disease  starts  as  a  papule,  developing  into  an  ulcer, 
which  may  become  quite  extensive.  It  extends  laterally  by  the  for- 
mation of  minute,  dermal,  and  subdermal  abscesses.  A  superficial 
crust  covers  a  red  granulating  mass,  which  is  verrucous,  with  sharp, 
elevated  borders,  and  exudes  a  seropurulent  secretion  (Fig.  14). 

Microscopically  there  is  extensive  tissue  hyperplasia,  containing 
giant  cells,  small  abscesses,  detritus,  and  the  organisms.     The  sur- 


r * 

! 

.a'.1 

7.   ■»   • 

•  ft*  ' 

R' 

X<£. 

W'Jk*^  V*- 

M 

%  V*' 

i 

M 

K 

% 

f 

Fig.  14. — Cutaneous  blastomycosis.     (Hyde.) 

rounding  tissue  shows  chronic  inflammatory  changes  with  the  presence 
of  giant  and  mast  cells. 

When  limited  to  the  skin  this  disease,  though  of  an  obstinate  nature, 
is  not  fatal. 

Systemic  infection,  however,  generally  results  in  death. 

Treatment. — Treatment  consists  of  curetting  or,  preferably,  complete 
extirpation. 

Improvement  and  cure  have  occasionally  been  obtained  by  the 
internal  administration  of  large  doses  of  potassium  or  sodium  iodide 
and  the  local  application  of  antiparasitic  solutions.  Bevan  has  advo- 
cated copper  sulphate  in  dosage  of  \  grain  t.  i.  d.,  increasing  it  to  \ 
grain  t.  i.  d.,  and  externally  a  1  per  cent,  copper  sulphate  wash. 


CHAPTER  V. 
TUMORS. 

The  word  tumor  is  often  used  by  the  clinician  in  a  general  and 
indefinite  way  to  designate  any  abnormal  swelling  of  circumscribed 
extent,  without  reference  to  the  cause  or  precise  character  of  the 
lesion.  Etymology  justifies  this  use;  but  custom  has  narrowed  its 
application.  It  is  therefore  proper  to  restrict  the  meaning  of  the 
term,  so  that  by  its  use  we  may  denote  any  circumscribed  new  growth 
of  tissue,  derived  from  some  pre-existing  normal  body  tissue  by  pro- 
liferation of  the  constituent  cells,  which  shows  greater  or  less  departure 
from  the  typical  structure  and  functions  of  the  parent  tissue,  which 
serves  no  useful  purpose,  and  which  generally  is  not  restrained  within 
definite  growth  limits.  Tumors  are  then  independent,  or  as  Thoma 
characterizes  them,  "autonomous"  new  growths.  They  may  arise 
in  any  tissue,  the  cells  of  which  are  capable  of  reproduction  and  the 
smaller  bloodvessels  of  which  are  competent  to  nourish  the  newly 
developing  structure.  The  process  of  cell  division  and  of  development 
of  new  bloodvessels  are  in  general  similar  to  those  of  normal  tissue 
growth,  regeneration,  and  repair.  The  finer  details  of  nuclear  divi- 
sion by  karyomitosis  are,  however,  frequently  atypical,  and  the  cellu- 
lar growth  often  shows  an  exuberant  development  well  expressed  by 
the  word  "lawless."  The  cells  composing  tumor  growths  are  largely 
subject  to  heredity,  and  hence  the  histology  of  a  given  tumor  usually 
enables  us  to  determine  its  tissue  paternity. 

Etiology. — The  etiology  of  tumors  is  a  very  complex  and  difficult 
subject,  which  can  be  only  briefly  touched  upon  here  in  its  more 
important  aspects. 

Having  a  bearing  upon  the  occurrence  of  tumors,  the  following  are 
distinctly  recognized : 

Age. — Though  tumors  are  most  frequent  in  adult  and  advanced  life, 
there  is  a  tendency  for  those  of  the  connective-tissue  type  to  occur 
somewhat  earlier  than  those  of  the  epithelial  type. 

Sex. — While,  in  general,  malignant  tumors  are  about  twice  as  fre- 
quent in  females  as  in  males,  malignant  tumors  of  the  stomach,  tongue, 
and  lips  are  more  common  in  males.  On  the  other  hand,  tumors  of 
the  breasts  and  reproductive  organs  are  far  more  common  in  females. 

Race. — While  carcinoma  is  common  in  the  white  race — especially 
in  the  female  breast  and  uterus,  it  is  a  striking  fact  that  this  form 
of  tumor  is  exceedingly  rare  in  the  negro  race — where  tumor  formation 
in  these  organs  is  far  more  frequent  in  the  form  of  fibromata. 


INNOCENCE  AND  MALIGNANCY  IN  TUMORS  75 

Local  Predisposing  Factors  in  the  Development  of  Tumors. — Though 
the  part  played  by  local  injuries  in  the  formation  of  tumors  is  a 
matter  not  clearly  understood,  it  has  frequently  been  observed  that 
while  bruises  or  contusions — especially  those  involving  the  bones — 
are  sometimes  followed  by  the  formation  of  malignant  tumors  of  con- 
nective-tissue type — sarcoma,  osteosarcoma,  etc. — repeated  injury  or 
long-continued  irritation  is  more  liable  to  be  followed  by  the  formation 
of  malignant  tumors  of  the  epithelial  type.  Such  an  observation  is 
especially  applicable  in  connection  with  tumors  of  the  sphincters  of 
the  body  and  tumors  of  the  breast  and  stomach  following  prolonged 
inflammation. 

While  Volkmann's  theory  of  the  influence  of  trauma  undoubtedly 
represents  one  of  the -factors  active  in  the  production  of  malignant 
tumors,  more  stress  has  recently  been  placed  on  Cohnheim's  theory 
advocating  the  occurrence  of  tumors  as  the  result  of  the  growth  of 
superfluous  or  displaced  embryonal  cells.  Ribbert,  recognizing  the 
importance  of  both  of  these  theories,  considers  another  factor  essential, 
viz.,  the  separation  of  cells  from  their  normal  relationships  by  em- 
bryonal or  postfetal  developmental  processes,  by  trauma  or  inflam- 
matory processes;  the  dissociated  cells  growing  independently  and  in 
limitless  fashion,  because  the  organism  has  lost  control  over  them. 

The  theories  advocating  bacteria  and  other  parasites  as  a  cause 
have  never  received  very  strong  support,  though  many  observers  have 
been  impressed  with  the  occurrence  in  some  tumors  of  protozoa-like 
bodies.  The  striking  analogy  which  exists  between  the  clinical  course 
of  cancer  and  some  of  the  chronic  infectious  diseases  renders  this 
theory  at  least  reasonable.  The  theory  of  the  communicability  of 
cancer,  still  to  be  proved,  finds  some  of  its  strongest  advocates  among 
the  supporters  of  this  origin  of  cancer. 

While  the  communicability  of  cancer  has  never  been  proved  in 
man,  some  of  the  most  interesting  and  important  of  the  modern 
research  work  on  cancer  has  shown  that  it  is  possible  to  transplant 
pieces  of  cancer  tissue  from  one  animal  to  another  of  the  same  species 
and  continue  this  process  through  many  generations  of  tumor  growth. 

Ehrlich  has  even  secured  active  immunity  against  cancer  in  mice 
by  injection  of  the  living  cells  of  slightly  virulent  strains  of  mouse 
carcinoma. 

Innocence  and  Malignancy  in  Tumors.— There  is  no  sharp  dividing 
line  between  innocence  and  malignancy  in  tumors,  for  while  such 
tumors  as  fibromata  are  always  clearly  benign,  and  small  round- 
celled  sarcomata  always  clearly  malignant,  there  are  tumors  belonging 
to  the  same  connective-tissue  type  group  which  occupy  an  interme- 
diate position.  Such,  for  example,  are  the  so-called  endotheliomata, 
gliomata,  and  giant-cell  sarcomata.  Furthermore,  there  is  some 
evidence  that  a  benign  adenoma,  when  existing  in  such  an  organ  as 
the  female  breast,  may  be  excited  to  malignancy  through  the  agency  of 
a  concurrent  inflammatory  process;    and  that  special  potentialities 


76  TUMORS 

of  malignancy  may  exist  in  some  benign  tumors  merely  in  relation 
to  their  anatomic  location  is  evidenced  by  the  frequency  with  which 
some  papillomata  of  the  larynx,  and  urinary  bladder,  and  adenomata 
of  the  uterus  and  large  intestine  assume  malignant  character. 

Malignancy,  then,  being  a  relative  term,  and  its  signs  developing 
irregularly  with  the  growth  of  the  tumor,  reliance  for  its  diagnosis 
must  be  placed,  not  upon  one  attribute  of  the  tumor,  but  upon  several 
taken  in  conjunction  with  each  other.1 
Such  attributes  are  as  follows: 
Gross  or  Clinical: 
Rapidity  of  growth. 
Invasion  of  adjacent  tissues  by  eccentric  or  peripheral  growth 

or  infiltration. 
The  tendency  to  local  recurrence  after  removal. 
The  formation  of  metastases. 
The  tendency  to  produce  cachexia. 
Microscopical: 

Abundance  of  mitoses,  especially  of  abnormal  types. 
Evidences  of  "lawlessness"  and  variation  in  size  of  cells,  and 

degree  of  departure  from  normal  types. 
Poor  structure  of  bloodvessel  walls  and  tendency  to  hemorrhage. 
Relatively  larger  size  of  nucleus. 
Tendency  to  degeneration. 
While  it  is  an  obvious  corollary  that  conditions  opposite  to  those 
stated  in  the  previous  list  point  to  innocence  in  tumors,  there  are  a 
few  exceptions  which  it  is  well  to  bear  in  mind.    For  example,  while 
degeneration  is  most  common  in  tissues  whose  rapidity  of  growth 
outruns  its  blood  supply,  and  in  tissues  which  are  so  lawless  and 
unstable  as  to  have  little   vital   resistance,   nevertheless  it   is  not 
uncommon  to  find  many  types  of  degeneration  in  even  the  most 
benign  tumors.    Such,  for  example,  are  hyaline,  amyloid,  fatty,  album- 
inous, calcareous,  or  mucoid  degenerations. 

Furthermore,  while  most  benign  tumors  are  circumscribed,  some, 
such  as  a  few  lipomata,  may  be  diffuse;  even  benign  tumors  may 
recur  if  not  completely  removed;  and  some  benign  tumors — angio- 
mata— may  be  largely  composed  of  bloodvessels,  many  of  which  have 
poorly  formed  walls,  with  some  tendency  to  hemorrhage. 

Treatment. — The  treatment,  in  general,  of  all  operable  tumors,  is 
essentially  surgical,  the  character  of  the  operation  being  dependent 
upon  the  character  and  location  of  the  tumor.  (See  chapters  on 
Special  and  Regional  Surgery.)  While  a  few  non-operative  procedures 
for  the  treatment  of  tumors — of  which  the  use  of  caustics,  the  various 
forms  of  radiant  energy,  and  Coley's  serum  are  examples — are  known, 
these  methods  have  their  most  frequent  applicability  in  instances 

1  According  to  the  conception  of  malignancy  here  used,  this  term  would  not  apply 
to  the  effect  of  pressure  of  a  tumor  on  a  neighboring  vital  organ  or  interference  with  its 
function  through  pressure  or  displacement. 


SPECIAL  VARIETIES  OF  TUMORS  77 

where  consent  for  operation  cannot  be  obtained  or  instances  of  inoper- 
able malignant  tumors. 

While  there  are  occasional  exceptions  in  the  treatment  of  some  cysts, 
the  cardinal  rule  of  procedure  in  the  case  of  all  operable  tumors  is 
removal  in  their  entirety,  as  even  the  most  benign  tumors  will  return 
if  only  partially  removed,  and  innocent  cysts  will  often  be  reformed  if 
a  portion  of  the  cyst  wall  be  allowed  to  remain. 

Classification. — The  pathologic  classification  of  tumors  is  most 
conveniently  based  upon  their  anatomic  structure.  They  may  be 
divided  into  the  following  groups: 

Connective-tissue  Type. 
Fibroma,  .  Endothelioma, 

Lipoma,  Glioma, 

Myxoma,  *      .        /  Hemangioma, 

Chondroma,  ngiomaj  Lympiiang}oma) 

Osteoma,  yr  r  J  Leiomyoma, 

Myeloma,  \oma  j  Rhabdomyoma, 

Sarcoma,  Neuroma. 

Epithelial-tissue  Type. 
Papilloma,  Carcinoma, 

Adenoma,  Epithelioma. 

Mixed  Type. 
Teratoma . 

Special  Tumor  Types. 

Chorion-epithelioma  or  deciduoma,         Hypernephroma, 

Psammoma. 

SPECIAL   VARIETIES    OF   TUMORS. 

Fibroma. — The  gross  and  microscopic  features  of  fibroma  resemble 
those  of  connective  tissue.  They  may  be  hard,  fibroma  durum,  or  they 
may  be  soft,  fibroma  molle.  Generally  they  are  circumscribed  masses, 
frequently  encapsulated.  They  vary  in  shape,  sometimes  growing  as 
papillomatous  masses,  or  as  polypi  seen  in  the  nose,  or  they  may  be 
diffuse.  Many  of  these  growths,  especially  the  firmer  ones,  present 
a  white  surface  in  which  the  fibrous  strands  may  be  seen  interlacing 
in  various  directions.  Fibromata  may  occur  anywhere  in  the  body, 
but  are  found  especially  in  the  skin,  periosteum,  fascia,  uterus,  and 
mammary  gland.  The  firm  fibromata  are  usually  oval  or  globular, 
smooth,  movable,  very  hard,  generally  single,  and  painless  unless 
attached  to  a  nerve.  The  softer  forms  are  smooth,  globular,  elastic, 
soft,  and  painless.  Tumors  of  this  class  are  usually  of  slow  growth, 
and  do  not  give  rise  to  true  metastasis. 


78 


TUMORS 


Microscopically,  fibromata  consist  of  connective  tissue  showing 
variable  proportions  of  cellular  elements.  The  hard  varieties  show 
few  cells  and  bloodvessels;  the  softer  ones,  on  the  contrary,  are  more 
cellular,  and  generally  have  a  richer  blood  supply.  They  often  con- 
tain elastic  tissue.  Mucoid,  myxomatous,  and  fatty  changes  are  com- 
mon. Keloid  is  a  form  of  fibroma  which  develops  in  scar  tissue  after 
injury  or  operation. 

Lipoma. — The  structure  of  tumors  of  this  class  is  like  that  of  ordi- 
nary adipose  tissue.  They  are  often  found  in  the  subcutaneous  tissue 
about  the  neck,  shoulders,  axillae,  and  groins.  Less  frequently  they 
are  found  in  the  kidneys,  intestine,  and  other  viscera.  They  are  of 
slow  growth,  and  sometimes  follow  injury.     They  are  benign,  but 


Fig.  15. — Intracanalicular  fibroma  of  breast. 

occasionally  cause  disturbances  by  pressure.  They  form  circumscribed 
and  encapsulated,  lobulated,  pseudo-fluctuating,  painless,  soft  elastic 
tumors,  generally  single,  but  occasionally  multiple,  and  grow  slowly 
(Fig.  16).  A  diffuse  form  is  known,  occurring  most  frequently  in  the 
neck.  A  dimpling  of  the  skin  is  often  evident  when  these  tumors  are 
pinched  up  between  the  thumb  and  finger. 

Myxoma. — Tumors  of  this  class  are  closely  related  to  the  fibromata. 
A  pure  myxoma  is  unknown.  Myxomata  are  rather  soft,  gelatinous 
tumors,  of  various  shapes  and  size.  The  outlines  are  well  defined; 
and  when  growing  from  mucous  membranes  they  form  polypi.  They 
consist  of  stellate  and  spindle-shaped  connective-tissue  cells;  and  the 
tissue  spaces  are  filled  with  a  substance  resembling  mucin.  Their 
appearance  is  like  that  of  certain  edematous  fibromata.    Myxomata 


SPECIAL   VARIETIES  OF  TUMORS 


79 


have  been  found  in  the  skin,  breast,  brain,  and  spinal  cord.  Most  of 
the  soft  nasal  polypi  belong  to  this  class.  As  with  fibromata,  growth  is 
usually  slow. 

Chondroma. — This  group  includes  tumors  made  up  of  hyaline  or 
fibrocartilage.    On  section  they  have  a  cartilaginous  appearance  and 


Fig.  16. — Lipoma,  showing  characteristic 
lobular  appearance. 


Fig.  17. — Chondroma. 


are  often  encapsulated.  Areas  of  ossification  or  mucoid  degeneration 
are  common.  They  may  arise  from  tissues  which  normally  contain 
cartilage,  but  they  are  often  found  where  none  normally  exists,  as  in 


Fig.  18. — Cancellous  osteomas  springing  from  the  diploe.     (Musee  Dupuytren.) 


the  testicles,  bone,  parotid  glands,  mammse,  etc.  Multiple  chondro- 
mata  are  occasionally  seen  on  the  hands  and  feet  (Fig.  17).  Growth  is 
slow  and  they  are  benign.  Very  rarely  metastasis  occurs.  Mixed 
forms  of  cartilaginous  tumors  are  common;  most  of  those  in  the 
parotid  and  testicles  belong  to  this  class. 


so 


TUMORS 


Osteoma.  -  -An  osteoma  is  a  new  growth  composed  of  bony  tissue. 
Two  varieties  are  recognised:  the  spongy  or  cancellous  and  the  com- 
pact. The  spongy  osteoma  is  most  frequently  found  at  the  ends  of 
the  long  bones  of  the  limbs,  or  growing  from  the  cranium  (Fig.  18). 
It  grows  very  slowly,  and  rarely  causes  any  discomfort  unless  it  presses 
upon  a  nerve  trunk  or  important  organ. 

The  compact  osteoma  usually  grows  from  the  bones  of  the  skull. 
Tt  is  generally  sessile  and  solitary,  and  may  grow  into  the  interior 
of  the  skull,  into  frontal  sinus,  or  into  the  cavity  of  the  orbit  or  nose. 

Exostoses  are  bony  tumors 
growing  upon  the  surface  of 
bones.  These  formations  some- 
times occur  in  muscles  and  ten- 
dons, especially  at  their  points  of 
attachment  to  the  skeleton. 

The  name  odontoma  is  applied 
to  an  osseous  growth  in  connec- 
tion with  teeth. 

Myeloma. — Occupying  a  posi- 
tion intermediary  between  the 
osteomata  and  osteosarcomata 
are  those  bone  tumors  known  as 
myelomata  which  are  considered 
by  Bland-Sutton  to  form  a  class 
distinct  from  both. 

They  are  composed  of  tissue 
resembling  the  red  marrow  of 
bone  and  differ  from  sarcomata 
in  not  being  malignant.  They 
occur  most  frequently  in  the 
cancellous  tissues  at  the  ends  of 
the  long  bones.  The  cut  surface 
of  the  tumor  usually  presents  a 
deep  red  or  maroon  color.  The 
tumor  grows  slowly,  expands  the 
bone,  and  thins  the  osseous  cap- 
sule while  expanding  it  until  the 
bony  shell  is  so  thin  that  it  crepi- 
tates when  pressed  by  the  finger  (Fig.  19).  Microscopically  myelo- 
mata abound  in  large  multinuclear  cells  (giant  cells)  imbedded  in 
round  or  spindle  cells.  If  the  giant  cells  do  not  greatly  predomi- 
nate, but  occur  with  round  or  spindle  cells  in  nearly  equal  pro- 
portions, the  tumor  becomes  more  nearly  allied  to  the  mixed-cell 
sarcomata. 

To  the  myeloid  type  of  tumor,  abounding  in  giant  cells,  which 
occurs  in  connection  with  the  gums,  the  name  epulis  is  applied 
(Fig.  20).     The  growth  of  these  tumors  is  slow. 


Fig.  19. — Lower  end  of  the  femur  in  sec- 
tion to  show  a  myeloma.  From  a  girl  seven- 
teen years  old;  she  was  known  to  be  alive 
and  well  five  years  after  amputation 
through  the  middle  of  the  thigh. 


SPECIAL    VARIETIES  OF  TUMORS 


M 


Sarcoma. — Tumors  of  this  class  arc  malignant  in  nature  and  are 
composed  of  miniature  mesoblastic  or  embryonic  connective  tissue, 


Epulis.     Myeloma  of  jaw. 


Fig.   21. — Sarcoma  of  too. 


in  which  cells  predominate  over  intercellular  stroma.     They  present 
divers  characters  structurally  and  clinically,  but  have  the  following  in 


common : 
6 


82 


TUMORS 


Each  cell  is  surrounded  by  a  varied  amount  of  intercellular  sub- 
stance which  has  no  definite  arrangement;  the  bloodvessels  have  very 
thin  walls,  and  are  often  merely  spaces  bounded  by  the  cells  themselves, 
hence,  the  frequency  with  which  hemorrhages  occur.  Dissemination 
usually  takes  place  by  the  bloodvessels.  Sarcomata  occur  most 
frequently  in  youth  and  early  middle  life.  Their  origin  may  some- 
times be  found  to  be  associated  with  trauma,  and  any  region  of  the 
body  may  be  involved.  The  most  common  locations  are  the  subcuta- 
neous areolar  tissue,  fascia, 
bones,  periosteum,  kidney, 
meninges,  lungs,  liver,  and 
alimentary  canal. 

Sarcomata  are  classified 
most  conveniently  according 
to  the  prevailing  types  of 
cell  present;  some  species 
being  subdivided  into  two  or 
more  varieties  and  some 
consisting  of  mixed  forms. 

Round-celled  Sarcoma. — 
This  group  consists  of  the 
small  and  large  round-cell 
sarcomata,  as  well  as  that 
known  as  lymphosarcoma 
and  gliosarcoma.  They  are 
among  the  most  malignant  of 
all  tumors.  Their  consist- 
ency is  usually  soft,  they 
are  vascular,  and  often  grow 
to  a  large  size  with  a  great 
tendency  to  disseminate. 

The  small-celled  variety 
consists  of  small  round  cells 
with  very  little  cytoplasm 
and  intercellular  stroma;  so 
little  in  fact  as  to  be  diffi- 
cult to  demonstrate.  The 
bloodvessels  are  thin-walled  channels  occurring  between  the  cells  of 
the  tumor  (Fig.  22.)  In  the  large  round-cell  variety  the  cells  are  larger 
but  variable  in  size,  the  nuclei  are  large  and  contain  prominent  nucleoli, 
the  cytoplasm  and  intercellular  substance  are  more  abundant,  and 
the  tumor  is  somewhat  firmer  than  the  small  round-cell  tumor. 

Lymphosarcomata  are  excessively  malignant,  arise  from  lymphoid 
tissue,  and  consist  of  small  round  cells  resembling  lymphoid  cells 
contained  in  a  delicate  reticulum. 

Gliosarcomata  occur  most  frequently  in  the  brain  and  retina,  and 
have  a  matrix  like  that  of  the  neuroglia  of  nerve  centres. 


Fig.  22. — Sarcoma  of  bone. 


SPECIAL  VARIETIES  OF  TUMORS 


83 


Spindle-cell  Sarcoma. — This  group,  consisting  of  the  small  and  large 
spindle-cell  sarcomata,  is  of  common  occurrence.     They  frequently 


Fig.  -•'•>. — Spindle-cell  sarcoma  of  chest 


Fig.  24. — Melanosarcoma  of  the  heel. 


are  found  in  the  periosteum,  subcutaneous  tissue,  muscle,  uterus,  and 
secreting  glands  (Fig.  23).      On  section  they  have  a  pinkish-white 


84  TUMORS 

color,  the  large  cell  type  being  soft  and  rapid  growing,  while  the  small 
cell  type  is  slower  in  growth  and  moderately  firm.  In  both  the  cells 
are  spindle-shaped,  often  arranged  in  fascicles  which  surround  the 
bloodvessels,  with  very  little  intercellular  substance.  In  the  large 
spindle  form  the  cells  frequently  contain  several  nuclei. 

Closely  allied  to  these  two  groups  in  the  morphology  of  the  cells 
are  the  melanosarcomata,  which  may  be  composed  of  round,  spindle, 
or  polyhedral  cells.  They  arise  in  the  choroid  and  in  the  skin,  espe- 
cially from  pigmented  moles.  They  receive  their  name  from  the 
fact  that  particles  of  brown  or  black  pigment  occur  in  the  cells  or 
intercellular  substance.  These  tumors  are  very  malignant,  and  have 
a  marked  tendency  to  form  metastases,  which  are  also  pig- 
mented (Fig.  24). 

Giant-celled  Sarcoma. — Giant-celled  sarcomata  are  tumors  closely 
resembling  the  myelomata  (already  described),  but  containing  sphe- 
roidal or  fusiform  cells  in  excess  of  giant  cells,  and  having  well-marked 
malignancy.  Some  originate  in  the  marrow,  are  soft  and  very  vascular, 
and  prone  to  form  metastases.  Others  originate  in  the  periosteum, 
are  firmer,  and  grow  up  by  a  new  formation  of  bone  tissue  as  an 
osteosarcoma. 

In  the  mixed  forms  of  sarcoma  the  types  of  cells  already  described 
are  found  associated  with  a  new  growth  of  bone  (osteosarcoma),  blood- 
vessels (angiosarcoma),  glands  (adenosarcoma),  connective  tissue, 
cartilage,  etc 

Endothelioma. — Many  pathologists  cling  to  this  term,  believing  that 
there  is  a  place  for  it  in  tumor  morphology.  Others  believe  that  a  par- 
ticular tumor  is  either  a  carcinoma  or  a  sarcoma  and  that  it  has  not 
originated  from  so-called  endothelium  which  preserves  an  individuality 
of  cell  structure.  In  the  writer's  opinion  these  neoplasms  are  in  the 
majority  of  instances  epithelial  growths. 

Glioma.— Under  this  heading  are  grouped  certain  tumors  which 
originate  either  from  the  neuroglia  of  the  brain  and  cord  or  from  the 
cells  lining  their  cavities.  It  is  only  rarely  that  they  take  their  origin 
in  the  retina.  They  do  not  often  gain  great  size  and  may  be  either 
hard  or  soft.  In  color  they  resemble  that  of  the  tissue  in  which  they 
are  found.  Histologic  studies  show  that  they  are  composed  of  neuroglia 
tissue  often  associated  with  true  nerve  tissue,  such  as  ganglion  cells 
and  nerve  fibres.  Evidences  of  old  and  recent  hemorrhage  are  com- 
mon. Growth  may  be  slow  or  rapid,  involving  the  brain  and  cord, 
but  not  their  membranes.  Gliomata  of  the  retina  are  generally 
malignant. 

Angioma.  Tumors  chiefly  composed  of  vascular  elements  are 
grouped  under  this  heading;  those  of  bloodvessel  origin,  as  heman- 
gioma, and  those  of  lymph  vessel  source,  as  lymphangioma. 

Hemangioma. — Several  varieties  of  hemangioma  are  recognized.  In 
the  case  of  the  "port  wine"  skin  discolorations,  birth  marks,  or  nevi, 
it  is  doubtful  whether  there  is  any  formation  of  new  bloodvessels  or 


SPECIAL  VARIETIES  OF  TUMORS 


85 


not;  some  believe  that  the  growth  is  due  to  dilatation  or  hypertrophy 
of  bloodvessels  originally  present.  There  is  another  variety  of  angioma 
which  consists  of  communicating  blood  spaces  bounded  by  endothelium 
and  connective-tissue  walls.  These  are  known  as  cavernous  angiomata 
(Fig.  25). 

The  hemangiomata  are  small  or  large,  of  a  bluish,  purple,  or  reddish 
color,  and  sometimes  showing  pulsations.  They  bleed  easily.  The 
diffuse  simple  angiomata,  angioma  telangiectoides,  are  usually  found 
in  the  skin,  especially  in  the  region  of  the  neck  and  head.  They  are 
mostly  of  congenital  origin.  The  cavernous  angiomata  are,  on  the 
other  hand,  generally  found  in  the  liver. 

Lymphangioma. — Lymphangiomata 
consist  of  growths  fo'rmed  either  of 
dilated  or  newly  developed  lymph 
vessels.  Apart  from  differences  as  to 
their  contents,  they  have  essentially 
the  same  structural  features  as  the 
angiomata  of  bloodvessel  origin.  Thus 
we  have  lymphatic  nevi,  lymphatic 
telangiectasis,  and  cavernous  lymphan- 
gioma; whereas  those  which  contain 
chyle  are  termed  chylangiomata. 

Myoma. — Tumors  of  this  group 
consist  either  of  striped  (rhabdo- 
myoma) or  unstriped  (leiomyoma) 
muscle  tissue. 

Rhabdomyoma. — The  rhabdomyo- 
mata  are  rare,  and  have  most  often 
been  found  in  connection  with  the 
genito-urinary  tract,  especially  the 
kidneys.  They  appear  generally  in 
childhood,  and  are  sometimes  asso- 
ciated with  sarcomatous  tissue.  The 
size  of  these  growths  is  small.  The 
characteristic  histologic  features  con- 
sist in  the  presence  of  striated  muscle 
tissue,  of  smaller  size  than  normal 
and  rather  irregularly  arranged. 

Leiomyoma. — The  leiomyomata  are  known  best  under  the  name 
"  uterine  fibroids."  Many  of  them  are  of  very  large  size  and  they  may 
be  single  or  multiple.  They  are  usually  firm,  nodular,  and  of  whitish 
or  pinkish  color.  A  variable  amount  of  fibrous  tissue  is  generally 
present  in  them.  The  uterus,  especially  after  puberty,  is  their  chief 
point  of  origin;  less  frequently  they  occur  in  the  gastro-intestinal 
and  genito-urinary  tracts,  in  the  skin,  and  larynx. 

While  uterine  leiomyomata  may  occasion  neither  inconvenience 
nor  suffering,  they  frequently  give  rise  to  profuse  hemorrhage,  and  they 


Fig.  25. — Angioma  of  hand. 


86 


TUMORS 


may  cause  serious  symptoms  by  pressing  injuriously  on  the  ureters  or 
the  intestine,  or  by  complicating  pregnancy  and  parturition. 


Fig.  26. — Papilloma  of  the  tongue. 

Microscopically  leiomyomata  consist  of  smooth  spindle-shaped 
muscle  fibres  collected  into  bundles  irregularly  arranged  in  a  con- 
nective-tissue stroma.  Various 
degenerations  are  common,  such 
as  cyst  formation,  gangrene,  and 
calcification.  Sarcomatous  meta- 
plasia is  sometimes  observed. 

Neuroma. — In  the  strict  sense, 
a  neuroma  is  formed  of  prolifer- 
ated nerve  elements  proper,  but 
the  term  has  been  loosely  used 
to  include  all  new  growths  con- 
taining nerve  cells  or  nerve  fibres 
in  a  fibrous  matrix,  such  as  am- 
putation neuromata.  True  neu- 
romata are  rare,  but  tumor 
masses  containing  fibrous  tissue 
and  nerve  elements  are  fairly 
common. 

Papilloma.  —  Papillomata  are 
tumors  which  project  from  a 
cutaneous  or  mucous  surface  and 
consist  of  a  central  axis  of 
vascular  fibrous  tissue,  hyper- 
trophied  papilla3,  with  a  cover- 
ing of  epithelium,  which  resembles 
that  of  the  surface  from  which 
the  tumor  grows.  In  the  papillo- 
mata of  the  skin  —  commonly 
known  as  ivarts — the  covering 
consists  of  epidermis;  in  those  growing  from  mucous  membranes  it 
consists  of  the  surface  epithelium.     When  the  surface  epithelium 


Fig.  27. 


-Multiple  papilloma  of  larynx, 
(von  Bergmann.) 


SPECIAL   VARIETIES  OF  TUMORS  87 

projects  as  filiform  processes,  the  tumor  is  called  a  villous  papilloma, 
the  best  known  example  of  which  is  met  with  in  the  urinary  bladder. 
Papillomatous  growths  are  also  met  with  in  the  larynx  (Fig.  27),  in 
the  ducts  of  the  breast — the  so-called  duct  papilloma — and  in  the 
interior  of  certain  cystic  tumors  of  the  ovary.  Although  papillomata 
are  innocent,  when  subjected  to  irritation  they  may  become  the 
starting-point  of  cancer.  This  tendency  is  especially  well  marked 
in  the  papillomata  of  the  larynx  and  urinary  bladder,  which  may 
develop  into  papillary  epitheliomata;  in  the  duct  papillomata  of  the 
breast,  which  may  develop  into  duct  carcinomata,  and  in  the  case  of 
villous  papillomatous  growths  of  the  ovary,  which  may  become 
detached  and  transplanted  to  the  surface  of  the  peritoneum  in  large 
numbers. 

In  old  people  warty  growths  of  the  skin  may  develop  into 
epitheliomata. 

Adenoma. — The  adenomata  are  new  growths  of  epithelial  type, 
derived  by  proliferation  of  the  epithelium  of  mucous  and  cutaneous 
glands  or  of  the  more  specialized  epithelium  of  certain  gland-like  organs. 

The  epithelial  proliferation  is  accompanied  by  a  strictly  propor- 
tionate or  even  an  excessive  development  of  a  vascular,  connective- 
tissue  stroma;  and  the  resulting  structure — when  the  tumor  is  of 
glandular  origin — is  composed  of  new  formed  gland  spaces,  of  acinous 
or  tubular  type,  which  are  lined  by  a  single  or  by  several  superimposed 
layers  of  epithelial  cells.  The  epithelial  growth  shows  no  tendency  to 
overstep  the  growth  of  its  supporting  stroma,  and  generally  preserves 
a  fairly  typical  glandular  arrangement. 

There  is  no  invasion  of  neighboring  tissues  by  peripheral  infiltra- 
tion and  no  habit  of  metastasis.  Cystic  formation  is  common  and  quite 
characteristic  of  certain  adenomata,  especially  those  of  the  ovary. 
The  adenomata  form  a  very  large  and  variable  class.  On  the  one  hand, 
it  may  be  difficult  to  distinguish  a  given  specimen  from  a  mere  regen- 
eration or  hyperplasia  of  normal  gland  tissue;  on  the  other  hand,  it  is 
impossible  to  distinguish  certain  adenomata  from  the  malignant  car- 
cinomata. This  is  especially  the  case  with  adenomata  of  the  intestine 
and  uterus. 

Carcinoma  (Cancer). — The  carcinomata  are  malignant  tumors  com- 
posed of  epithelial  cells  arranged  in  the  form  of  columns,  atypical  acini 
or  alveoli  whose  walls  are  formed  of  connective  tissue.  The  cells,  while 
varying  in  shape  and  size,  closely  resemble  in  their  general  characters 
the  epithelial  cells  of  the  part  from  which  they  spring,  and  within 
the  alveoli  are  not  separated  from  each  other  by  stroma,  thus  differing 
from  the  sarcomata.  In  the  fibrous  tissue  stroma  the  bloodvessels 
and  lymph  vessels  ramify. 

Carcinomata  are  divided,  according  to  the  type  of  cell  of  which 
they  are  formed,  into  spheroidal,  cylindrical,  and  squamous  forms — 
members  of  the  last  group  being  always  known  as  epitheliomata, 
occurring  in  the  skin  and  squamous-celled  mucous  membranes. 


88  TUMORS 

The  spheroidal  cell  forms  always  spring  from  glandular  structures, 
and  are  often  termed  carcinoma  simplex. 

Cylindric  carcinomata  may  spring  from  any  pre-existing  cylindric 
epithelium,  but  are  found  most  commonly  in  connection  with  the 
gastro-intestinal  tract  and  uterus. 

While  the  evidences  of  malignancy  in  carcinomata  occur  according 
to  the  general  rules  already  laid  down  for  malignancy   in  tumors. 


Fig.  28. — Carcinoma  of  the  female  mammary  gland  with  metastases  in  the  axillary 

lymph  glands. 

special  stress  is  laid  upon  the  fact,  that  while  in  the  related  forms  of 
benign  growth,  of  which  papillomata  of  the  skin  and  rectum  may 
be  taken  as  examples,  the  growth  does  not  extend  below  the  basement 
membrane;  in  the  carcinomata  of  these  situations  the  basement 
membrane  is  pierced  by  the  tumor  cells. 

In  the  cuboidal  form  the  departure  from  the  benign  adenoma  type 
is  indicated  by  a  piling  up  of  the  rows  of  lining  cells,  which  lose  their 


SPECIAL  VARIETIES  OF  TUMORS  89 

direct  relationship  to  the  basement  membrane  and  ultimately  may 
form  alveoli  instead  of  acini,  ceasing  to  reproduce  the  glandular  type. 

Carcinomata  show  the  strongest  tendency  not  only  to  local  recur- 
rence but  also  to  metastasize  in  distant  regions.  Extension  of  the 
growth  is  partly  by  the  direct  infiltration  of  neighboring  tissues  and 
partly  by  way  of  the  lymph  channels  (Fig.  28). 

Degenerative  changes  are  very  common,  occurring  most  frequently 
as  fatty  or  myxomatous  degeneration. 

From  the  colloidal  form  cf  degeneration,  a  type  of  carcinoma  occur- 
ring most  commonly  in  the  stomach  and  peritoneum,  has  received  its 
name — colloidal  carcinoma. 


•'-;    <* 


"*£**  ;  -*•'"  '  i'//- 


I  u 


■u. 


*$&':;/ 


Fig.  29. — Scirrhous  carcinoma  of  breast. 

Carcinomata  produce  poisonous  products  which  impair  the  general 
health  of  the  individual,  resulting  in  a  condition  known  as  cancerous 
cachexia. 

The  majority  of  carcinomata  (70  per  cent.)  occur  between  the 
ages  of  forty  and  seventy.  Under  fifteen  years  the  disease  is  scarcely 
known.  Trauma  and  chronic  irritation  are  important  factors  favoring 
carcinomatous  development  in  many  cases;  but  as  to  the  real  exciting 
factors  we  know  very  little.  Being  unable,  therefore,  to  remove  the 
cause,  in  view  of  the  fact  that  carcinoma  is  not  only  one  of  the  com- 
monest of  surgical  diseases,  the  ability  to  diagnosticate  the  condition 
in  its  early  forms  becomes  a  matter  of  greatest  importance,  enabling 
the  removal  of  the  entire  process  before  its  extension  has  made  the 
condition  inoperable  and  its  termination  fatal. 


90 


TUMORS 


Spheroidal-celled  Carcinoma. —  Spheroidal-celled  carcinomata  are 
usually  subdivided,  according  to  the  relative  abundance  and  density 
of  the  fibrous  stroma,  into  ''scirrhous"  (Fig.  30)  and  "medullary" 
(Fig.  31).     No  definite  line,  however,  separates  these  groups. 

Scirrhous  Carcinoma. — Scirrhous  carcinoma  occurs  as  a  firm,  hard, 
nodular  growth,  depressed  in  the  centre  owing  to  contraction  of  the 
fibrous  tissue.  This  contraction  is  very  characteristic  of  scirrhus  of 
the  breast,  where  it  causes  retraction  of  the  nipple  and  puckering  of 
the  skin  (Fig.  31).  The  cut  surface  is  of  grayish-white,  semitranslucent 
appearance,  like  that  of  an  unripe  pear.  From  the  central  mass  stellate 
processes  of  new  growth  may  radiate  for  an  indefinite  distance  into  the 
surrounding  tissue  (Plate  III).  Microscopically  scirrhous  carcinoma 
consists  of  collections  of  spheroidal  epithelial  cells  of  various  sizes  sur- 


4m  ^^^^M^3.p^ 


Fig.  30. — Medullary  carcinoma  of  breast. 

rounded  by  an  excess  of  connective-tissue  stroma.  A  single  alveolus 
may  consist  of  many  or  only  two  or  three  cells.  The  overlying  skin 
may  become  involved,  slough,  and  an  ulcer  may  result,  or  the  infil- 
tration may  become  so  dense  as  to  have  the  consistence  of  cartilage, 
forming  a  "scirrhus  en  cuirasse."  To  that  form  of  epithelioma  follow- 
ing an  eczematous  inflammation  of  the  nipple  occurring  beneath  the 
inflamed  area  but  having  no  direct  continuity  with  it  the  name 
Paget's  disease  has  been  given. 

Scirrhous  carcinoma  is  most  common  in  women  after  the  age  of 
forty  and  is  of  very  slow  growth,  although  the  lymph  nodes  in  the 
neighborhood  may  be  early  involved  by  secondary  deposits. 

While  the  female  breast  is  by  far  the  most  common  seat  of  scirrhous 
carcinoma,  it  has  been  found  in  the  uterus,  stomach,  and  esophagus. 


PLATE  III 


Extensive  Carcinoma  of  Breast. 

Colored  photograph  of  a  fresh  specimen.     (Lumiere  method.) 


SPECIAL  VARIETIES  OF  TUMORS 


91 


Eneephahid  Carcinoma.  —  Encephaloid  carcinomata  occur  most 
commonly  in  the  breast,  ovary,  stomach,  liver,  and  bladder  as  soft, 
elastic,  rapidly  growing  tumors,  quickly  terminating  in  ulceration, 
involvement  of  neighboring  glands,  and  general  dissemination  through 
the  body.  The  stroma  is  scanty  in  amount  and  the  spheroidal  epithelial 
cells  are  contained  in  large  alveoli.  Evidences  of  rapid  cell  division, 
degeneration,  and  hemorrhage  are  common. 


Fig.  31. — Atrophic  scirrhous  carcinoma  of  the  breast,     (von  Bergmann.) 


Cylindric-celled  Carcinomata. — Cylindric-celled  carcinomata  consist 
of  cells  derived  from  cylindric  or  columnar  epithelium.  They  occur 
most  frequently  in  the  stomach,  intestines,  and  uterus,  and  may 
occur  in  the  breast  as  duct  cancers.  They  often  begin  as  papillary  out- 
growths from  the  mucous  membranes,  especially  when  growing  in  the 
rectum,  where  they  are  frequent. 

Microscopically,  these  tumors  consist  of  more  or  less  acinus-like 
tubular  structures  composed  of  several  layers  of  epithelial  cells. 
These  acini,  which  are  bound  together  by  a  delicate  stroma,  may,  in 
the  later  stages,  become  completely  filled  with  epithelial  cells. 


92 


TUMORS 


In  these  tumors  there  may  be  seen  all  gradations  of  structure  be- 
tween a  definite  adenoma  and  a  typical  carcinoma;    hence  the  name 


Fig.  -i~2. — Epithelioma  of  the  thigh. 


applied  to  some  of 
or    adenoca  re  in  o  m  a . 


Fig.  33. — Epithelioma  of  sternal  region. 


these  intermediary  forms  of  malignant  adenoma 
These  gradations  are  seen  especially  in  growths 
from  the  uterine  endometrium. 
In  these  cases  the  extension  of 
the  growth  into  the  muscular 
coats  is  an  important  indication 
of  malignancy. 

Epithelioma. — Squamous-celled 
carcinoma  or  epithelioma  usually 
occurs  at  the  junction  of  skin 
and  mucous  membrane.  It  is 
frequently  found  on  the  lower  lip, 
penis,  and  tongue,  less  commonly 
on  the  gums,  palate,  tonsils, 
larynx, pharynx,  esophagus,  blad- 
der or  uterus,  and  general  cuta- 
neous surface;  rarely  on  the 
hands  and  feet.  It  has  fre- 
quently been  known  to  follow 
chronic  ulceration  and  prolonged 
irritation.    It   often   starts  as  a 


SPECIAL  VARIETIES  OF  TUMORS 


93 


cauliflower  mass  of  warts  of  horny  consistence  or,  more  commonly,  as 
a  warty  nodule  or  a  fissure.  These  soon  become  ulcers,  with  raised, 
exerted,  sinuous,  and  indurated  edges  and  a  hard,  warty,  and  irregu- 
lar base  which  exudes  an  ichorous  fluid.  Lymph-node  involvement 
is  usually  early  and  extensive. 

Microscopically j  these  tumors  consist  of  solid  columns  of  epithelium, 
which  have  perforated  the  basement  membrane  and  have  grown  into 
the  connective  or  other  underlying  tissue.  The  columns  are  surrounded 
by  an  imperfectly  fibrillated  stroma  or  round  connective-tissue  cell 
infiltration.  The  epithelial  cells  penetrate  into  the  lymph  spaces  and 
follow  those  channels  which  intercommunicate.     Transverse  sections 


Fig.  34. — Basal-celled  epithelioma  of  face. 


of  the  epithelial  masses  show  typical  epithelial  nests.  When  these 
cells  become  compressed  they  form  concentrically  arranged  masses 
which  undergo  keratinization  and  are  known  as  epithelial  pearls. 
Mitotic  figures  are  usually  abundant  in  the  epithelial  cells,  in  many 
of  which  the  peripheral  prickles  or  spines  can  be  detected.  There  is 
a  marked  tendency  to  degeneration,  causing  ulceration  and  hemor- 
rhage, and  extension  occurs  by  direct  infiltration  and  through  the 
lymphatics  (Figs.  32  and  33). 

Rodent  Ulcer. — Rodent  ulcer  is  the  least  malignant  form  of  epithe- 
lioma, and  arises  in  the  dermis  rather  than  from  the  surface  epithelium ; 
hence    the  term   basal-celled   epithelioma,  employed   by  Krompecher 


94  TUMORS 

(Fig.  33).  It  usually  occurs  on  the  face  and  is  most  common  on  the 
side  of  the  nose,  at  the  inner  angle  of  the  orbit,  on  the  forehead,  and 
the  prominence  of  the  malar  bone.  It  is  seldom  seen  in  early  life,  the 
growth  is  very  slow,  and  the  lymph  nodes  are  rarely  affected  by  second- 
ary growths.  The  ulcer  is  flattened,  the  edges  are  raised,  indurated, 
and  smooth.  Microscopically,  it  consists  of  irregular  ingrowths  from 
the  basal  epithelial  cells,  the  new-formed  cells  being  round  and  small, 
usually  not  more  than  one-third  the  size  of  the  cells  forming  an 
epithelioma. 

Teratoma. — There  is  a  class  of  abnormal  tissue  growth,  complex  in 
its  nature,  varying  from  the  double  monster  type  to  the  compound 
tumor  of  misplaced  embryonal  tissue,  which  results  from  abnormal 
development  of  embryonic  structures,  to  which  the  name  teratoma  is 
applied. 

These  tumors  are  derived  from  cells  capable  of  giving  rise  to  all 
the  tissues  of  the  individual,  and  are  divided  by  Adami  into  twin  and 
filial  teratomata. 

The  twin  type — of  which  the  fetal  inclusion  is  an  example — occurs 
as  an  autonomous  growth,  the  product  of  the  continued  development 
within  one  individual  of  another  individual  of  the  same  species. 

The  filial  type  is  due  to  the  segregation  and  subsequent  growth  of 
embryonal  cells,  which  are  capable  of  giving  rise  to  all  the  different 
tissue  types. 

As  examples  of  those  growing  from  non-germinal  blastomeres  may 
be  cited  the  epignathus,  from  excess  production  of  growing  point  cells 
at  the  superior  pole,  and  sacral  congenital  teratomata,  formed  in  a 
similar  way  at  the  inferior  pole. 

A  more  common  form  of  teratoma  is  that  derived  from  the  germinal 
blastomeres,  to  which  group  of  tumors  the  term  embryoma  is  frequently 
applied. 

The  germinal  blastomeres  may  become  misplaced  and  then  appear 
as  teratomata  of  the  cranium,  gill  clefts,  thoracic  cavity,  etc.;  but 
even  if  they  remain  in  the  ovary  or  testicle  they  may  still  show  a 
tendency,  in  postfetal  life,  to  assume  active  properties  of  growth  and 
become  the  testicular  and  ovarian  embryomata,  which  are  by  no 
means  uncommon. 

These  tumors,  exceedingly  complex  in  their  structure,  are  derived 
from  all  three  layers  (epiblast,  mesoblast,  and  hypoblast),  and  may 
contain  a  great  number  of  different  forms  of  tissue,  such  as  various 
forms  of  fibrillar  connective  tissue,  cartilage,  bone,  teeth,  hair,  skin, 
muscle,  and  glands. 

While  usually  benign,  these  tumors  may  assume  the  most  extreme 
malignancy — this  character  occurring  in  those  tumors  in  which  sar- 
comatous and  carcinomatous  elements  are  present. 

There  is  another  type  of  tumor,  intermediate  between  the  terato- 
mata and  the  simple  tumor,  which,  while  not  the  product  of  the  growth 
of  all  three  germinal  layers,  is  yet  mixed  in  type. 


SPECIAL  TUMOR  TYPES  95 

To  this  group  belong  various  tumors  of  the  kidney,  parotid,  sub- 
maxillary gland,  vagina,  and  breast. 

Such  tumors,  of  which  fibro-adenomata,  adenocarcinomata,  and 
chondrosarcomata  are  examples,  are  considered  mixed  tumors  because 
more  than  one  type  of  tissue  is  present  under  conditions  where  these 
tissues  have  assumed  the  characters  of  the  independent  growths. 

SPECIAL   TUMOR   TYPES. 

A  few  tumors  exist  which  are  of  unusual  form  and  structure,  which 
are  not  included  in  any  of  the  common  groups  of  tissue  types. 

These  have  distinctive  names,  and  include  peculiar  tumors  formed 
of  fetal  or  placental  tissue,  called  chorion  epithelioma  or  deciduoma; 
of  tissue  resembling  the  adrenals,  hypernephroma;  peculiar  tumors  of 
the  dura  mater,  called  psammoma,  etc. 

Deciduoma. — The  name  deciduoma  has  been  applied  to  a  form  of 
uterine  new  growth  occurring  in  connection  with  pregnancy  which  was 
formerly  thought  to  occur  as  a  result  of  the  proliferation  of  the  cells 
of  the  decidua,  but  which  recently  have  been  shown  to  have  their  origin 
more  frequently  in  the  chorion. 

Between  the  benign  form  known  as  hydatiform  mole  and  the  malig- 
nant forms  known  as  syncytioma  or  chorionepithelioma  there  is  no  sharp 
dividing  line,  although  most  hydatiform  moles  are  clearly  benign 
and  most  chorionepitheliomata  are  excessively  malignant.  The 
tendency  to  the  occurrence  of  chorionepithelioma  after  the  forma- 
tion of  hydatiform  mole  is  well  marked,  this  connection  having  been 
established  in  about  40  per  cent,  of  the  cases  on  record. 

Hydatiform  or  vesicular  mole  is  a  form  of  new  growth  having  a 
resemblance  to  a  bunch  of  grapes,  which  has  its  origin  in  the  chorionic 
villi.  The  translucent  vesicles,  of  which  it  is  formed,  contain  a  clear 
fluid,  vary  in  size  from  that  of  a  millet  seed  to  an  acorn,  and  spring 
from  other  vesicles  or  from  the  chorion  by  independent  pedicles. 

There  is  a  tendency  for  the  chorionic  villi,  in  this  condition,  to  infil- 
trate the  uterine  wall.  The  varying  degree  of  this  infiltration  is  a 
factor  which  makes  the  borderline  between  the  benign  and  the 
malignant  deciduomata  an  indistinct  one. 

Recently  attention  has  been  called  to  the  intimate  relationship 
between  the  occurrence  of  hydatiform  mole  and  lutein  cysts  of  the 
ovary. 

Chorionepithelioma. — The  malignant  form  of  deciduoma  is  usually 
known  as  chorionepithelioma.  These  tumors  usually  contain  elements 
derived  from  both  layers  of  the  chorion — Langhan's  cells  and  the 
multinucleated  cells  of  the  syncytium.  Inasmuch  as  they  always 
include  the  syncytial  layer,  they  are  sometimes  known  as  syncytioma. 

Their  most  important  clinical  feature  is  their  tendency  to  produce 
frequent  and  profuse  hemorrhage.  They  possess  a  great  tendency  to 
form  early  and  extensive  metastasis  because  of  the  proclivity  which 


96  TUMORS 

the  chorionic  epithelium  exhibits  of  penetrating  the  capillaries.  They 
are  among  the  most  malignant  of  tumors. 

To  the  naked  eye  the  tumor  appears  on  section  as  a  soft,  reddish 
mass.  Microscopically,  it  is  composed  of  large  polynuclear  cells  or 
cell  masses — syncytial  masses — appearing  in  regular  multinuclear 
strands,  and  of  more  transparent,  sharply  circumscribed,  polyhedral 
cells,  with  single  oval  nuclei.  They  often  contain  free  blood  and 
fibrin,  and  the  stroma  is  largely  made  up  of  the  tissue  they  invade. 

Hypernephroma. — The  name  hypernephroma  has  been  applied  to  a 
form  of  tumor  found  mainly  in  the  kidney,  arising  from  adrenal  nests 
or  masses  of  accessory  suprarenal  tissue,  having  the  structure  of  the 
zona  fasciculata  of  the  suprarenal  body. 

As  a  rule,  hypernephromata  are  malignant,  although  they  may  be 
benign.  They  occur  most  commonly  in  persons  past  middle  life,  and 
may  form  metastases,  which  extend  along  the  blood  stream  to  the 
lung,  liver,  muscles,  and  frequently  to  the  long  bones.  In  the  kidney 
the  tumor  is  usually  encapsulated  and  situated  near  the  cortex. 

Hypernephromata  histologically  present  wide  variations  which  ap- 
proach in  type  the  carcinomata,  endotheliomata,  and  angiosarcomata. 

The  stroma  is  composed  largely  of  a  network  of  capillaries,  in  the 
meshes  of  which  the  cells  are  enclosed.  An  alveolar  appearance  is 
often  seen.  The  cells  are  large,  polyhedral,  and  retractile,  containing 
fat  and  glycogen  droplets. 

The  cells,  lying  directly  upon  the  endothelium  of  the  capillaries, 
often  present  a  tubular  arrangement.  Mitosis  is  frequently  abundant, 
and  the  central  areas  of  the  tumors  are  very  prone  to  undergo  degen- 
eration.    Interstitial  hemorrhages  are  common  and  often  profuse. 

While  Lubarsch  considered  the  presence  of  glycogen  characteristic 
of  hypernephromata,  this  view  is  no  longer  tenable,  as  many  embryonic 
tissues  and  freely  growing  tumors  contain  glycogen  in  their  cells. 

Psammoma. — Psammomata  are  small  lobular  tumors,  often  multiple 
and  pedunculated,  growing  from  the  inner  surface  of  the  dura  mater  or 
the  pia  mater.  They  are  usually  composed  of  tissue  fibres,  sarcoma- 
tous or  endotheliomatous  in  character,  and  contain  variously  shaped 
calcareous  concretions  similar  in  appearance  to  the  so-called  brain 
sand. 

CYSTS. 

A  cyst  is  a  closed  sac,  containing  fluid  or  pultaceous  matter — a 
form  of  new  growth,  although  not  a  tumor  in  the  strict  sense  of  the 
word.     Cysts  may  be  classified  as  follows: 

I.  Cysts  formed  by  distention  of  pre-existing  cavities. 
II.  Cysts  of  new  formation. 
III.  Congenital  cysts. 
I.  Cysts  Formed  by  Distention  of  Pre-existing  Cavities. — These 
are  divided  into  three  groups:     (a)  Exudation  cysts;    (b)  retention 
cysts;   (c)  extravasation  cysts. 


CYSTS  97 

Exudation  Cysts.  Exudation  cysts  are  those  which  arise  from  the 
distention  of  cavities  which  have  no  secretory  ducts,  such  as  thyroid, 
Graafian  follicles,  and  bursa*.  In  the  thyroid  this  gives  rise  to  a  cystic 
goitre.  Graafian  follicle  cysts  may  be  multiple,  with  coalescent  walls 
and  communications  between  adjacent  cavities.  These  are  not  to 
be  confused  with  cystadenomata  and  papillary  cystadenomata.  Bur- 
sal cysts  occur  most  commonly  in  the  larger  bursse— -prepatellar  and 
olecranon — and  in  those  bursse  over  the  tuberosity  of  the  ischium  and 
the  great  trochanter. 

Retention  Cysts. — \Vhen  the  duet  of  a  gland  becomes  obstructed,  the 
secretion,  hindered  from  escaping,  accumulates  and  causes  a  dilatation 
of  the  ducts  and  acini. 

Examples  of  this  form  are  sebaceous  and  mucous  cysts  and  the  so- 
called  duct  cysts  of  the  salivary  and  lacteal  glands,  liver,  kidney,  and 
testicle. 

Sebaceous  Cysts. — Sebaceous  cysts  or  wens  result  from  physical 
change  of  secretory  material  so  that  mechanically  the  contents  accu- 
mulate and  also  from  obstruction  in  the  excretory  duct.  The  secre- 
tion collects  and  forms  a  tumor.  These  tumors  are  especially  common 
on  the  face  and  scalp,  but  may  occur  on  any  part  of  the  body.  They 
are  smooth,  round,  circumscribed,  movable  on  the  deeper  parts,  soft 
and  putty-like  in  consistence,  and  contain  inspissated  creamy  material. 
A  small,  black  spot  may  sometimes  be  detected  on  the  surface  of  the 
skin  over  them,  where  the  duct  opens. 

Mucous  Cysts. — Mucous  cysts  are  formed  by  the  dilatation  of 
mucous  glands  following  obstruction  of  their  ducts. 

They  are  most  common  in  connection  with  the  salivary  glands. 
When  these  occur  in  the  mouth,  they  are  known  as  rauulce.  Other 
common  examples  are  the  cysts  formed  by  the  dilatation  of  the  glands 
of  Bartholin  at  the  entrance  of  the  vagina. 

Extravasation  Cysts. — Extravasation  cysts  are  formed  by  the  extrav- 
asation of  blood  into  closed  cavities,  as  the  tunica  vaginalis  of  the 
testicle  (hematocele),  etc. 

II.  Cysts  of  New  Formation. — These  are  divided  into  four  groups: 

(a)  Serous  cysts. 

(b)  Degeneration  cysts. 

(c)  Parasitic  cysts. 

(d)  Implantation  cysts. 

Serous  Cysts. — Serous  cysts  are  supposed  to  be  formed  by  the 
accumulation  of  fluid  as  the  result  of  irritation,  pressure,  etc.,  in  the 
lymphatic  spaces  of  the  connective  tissue,  these  spaces  subsequently 
becoming  fused  into  a  single  cavity.  Adventitious  bursa?  developed 
over  prominences  of  bone  are  the  most  common  examples  of  this  form. 

Degeneration  Cysts. — Degeneration  cysts  result  from  degeneration 
and  liquefaction  occurring  in  the  substance  of  tumors,  especially  those 
which  are  succulent  and  of  rapid  growth.     Old  abscesses  may  also 
change  into  well-defined  cysts  of  this  kind. 
7 


98 


TUMORS 


To  this  group  may  also  be  added  the  ganglia,  which  are  cysts  formed 
in  connection  with  the  connective-tissue  structures  through  degenera- 
tion, in  the  majority  of  cases,  of  connective  tissue.  They  occur  about 
a  joint,  as  in  the  sheath  of  a  tendon,  and  are  most  commonly  seen  on 
the  dorsal  aspect  of  the  carpus  or  tarsus. 

Parasitic  Cysts. — Parasitic  cysts  are  produced  by  the  growth  within 
the  tissues  of  cyst-forming  parasites,  the  best  known  being  the  tenia 
echinococcus,  which  gives  rise  to  the  hydatid  cyst. 

Although  hydatid  cysts  may  occur  in  any  of  the  tissues  and  organs 
of  the  body,  they  are  most  frequently  found  in  the  liver. 


Fig.  35. — Echinococcus  cyst  of  liver.    Triangular  area  of  cyst  wall  removed  showing 

daughter  cysts. 


The  ova  of  the  parasite,  transmitted  from  the  dog,  gain  admission 
to  the  human  intestine,  are  there  hatched,  and  the  embryos  are  thence 
transported  to  some  other  part  of  the  body,  usually  by  the  portal  vein, 
where  they  lodge  and  form  cysts.  These  cysts  are  formed  of  an 
external  laminated  elastic  layer,  the  ectocyst,  and  of  a  lining  mem- 
brane or  parenchymatous  layer,  the  endocyst.  From  this  inner  layer 
brood  capsules  may  develop  from  which  daughter  cysts  may  form,  and 
from  these  in  turn  granddaughter  cysts  may  develop. 

Implantation  Cysts. — Implantation  cysts,  or  traumatic  dermoids,  are 
formed  by  the  displacement  of  portions  of  the  epidermis  through  a 
punctured  wound  into  the  underlying  connective  tissue.     The  dis- 


CYSTS 


99 


placed  epithelium  proliferates  and  forms  a  small  cyst,  the  most  fre- 
quent site  of  which  is  on  the  palmar  aspect  of  the  hand  and  fingers. 

III.  Congenital  Cysts. — These  are  divided  into  two  group-: 
(a)  Dermoid  cysts. 
(6)  Cysts  from  persistent  fetal  structures. 

Dermoid  Cysts. — Dermoid  cysts  of  the  simplest  form,  known  as 
sequestration  dermoids,  arise  in  detached  and  sequestrated  portions 
of  the  surface  epithelium,  mainly  in  situations  where,  during  embry- 
onic life,  coalescence  takes  place  between  skin-covered  surfaces.  They 
are  found  in  the  midline  of  the  trunk,  from  the  occipital  protuberance 
along  the  spine  to  the  coccyx,  through  the  perineum  (including  the 
scrotum  and  penis)  and  through  the  midline  of  the  abdominal  and 
thoracic  wall  of  the  neck.  In  the  face  and  neck  they  arise  in  the  lines 
of  the  facial  and  branchial  fissures. 


Fig.  36. — Ovarian  dermoid  bisected. 


A  dermoid  occasionally  takes  the  form  of  a  recess  lined  with  skin, 
examples  of  which  are  postanal  dimples,  the  coccygeal  or  pilonidal 
sinuses;  but  more  commonly  it  assumes  the  form  of  a  globular  tumor, 
consisting  of  a  central  cavity  lined  by  stratified  squamous  epithelium. 
This  cavity  is  filled  with  a  turbid  fluid  containing  desquamated 
epithelium,  fat-droplets,  cholesterine  crystals,  and  detached  hairs. 

Ovarian  dermoids  differ  in  several  respects  from  the  preceding. 
They  arise  from  the  epithelium  of  the  ovarian  follicles,  and  take 
the  form  of  unilocular  or  multilocular  cysts,  the  wall  of  which  con- 
tains skin,  mucous  membrane,  hair  follicles,  sebaceous,  sweat,  and 

The  cavity  of  the  cyst  usually  contains  a  pultaceous  mixture  of  shed 
mucous  glands,  nails,  teeth,  nipples,  and  mammary  glands  (Fig.  36). 
epithelium,  fluid  fat,  and  hair. 


100  TUMORS 

Cysts  from  Persistent  Fetal  Structures. — These  occur  in  obsolete  canals 
and  functionless  ducts. 

Among  the  former,  existing  in  the  human  embryo,  but  usually 
disappearing  before  birth,  are  the  thy ro glossal  duct,  the  branchial 
clefts,  and  the  postanal  gut.  Cysts  derived  from  these  structures  are 
frequently  called  tubulodermoids. 

Cysts  of  the  latter,  frequently  called  tubulocysts,  arise  in  connection 
with  the  vitello-intestinal  and  Gartner's  ducts,  the  urachus,  the  paro- 
ophoron, and  the  parovarium. 


CHAPTER  VI. 
SHOCK  AND  ALLIED  CONDITIONS. 

SHOCK. 

As  a  result  of  injury  or  strong  mental  (psychic)  impressions  a  con- 
dition of  depression  may  result  which  is  called  shock.  The  degree  of 
shock,  as  represented  by  clinical  manifestations,  varies  within  wide 
limits.  Thus,  there  may  be  only  a  feeling  of  slight  weakness  or  a 
temporary  loss  of  consciousness;  on  the  other  hand,  there  may  be 
evidences  of  complete  disorganization  of  the  vital  processes  from  which 
death  quickly  results. 

The  Explanation  of  Shock. — The  majority  of  writers  and  investi- 
gators have  taught  that  the  all-important  factor  in  the  development  of 
shock  is  loss  of  vasomotor  control.  This  vasomotor  theory  apparently 
was  suggested  first  by  Mitchell,  Keen  and  Morehouse.1  Fisher  as- 
sumed that  as  a  result  of  vasomotor  paralysis  large  quantities  of  blood 
accumulate  in  the  splanchnic  veins  and  that  the  heart  and  other  por- 
tions of  the  vascular  system  are  comparatively  empty.  This  inter- 
pretation of  shock  was  generally  accepted.  Yet  some  writers  have 
sought  to  explain  the  phenomena  of  shock  in  other  ways.  The  theory 
has  been  advanced  that  the  condition  is  due  to  impairment  of  the  func- 
tions of  the  brain  by  anemia,  caused  by  contraction  of  the  bloodvessels. 
Howell2  advanced  the  theory  that  "the  condition  is  due  fundamentally 
to  a  strong  inhibition  of  the  medullary  centres  (vasoconstrictor,  cardio- 
inhibitory)  leading  to  a  long  continued  suspension  of  activity,  partial 
or  complete."  Meltzer3  attributes  the  symptoms  to  a  tendency  to 
overactive  inhibition,  that  is,  stimulation  of  nerve  fibres  which  cause 
inhibition  will  inhibit  more  than  in  a  normal  state.  Yandell  Hendersen 
presented  the  theory  that  the  symptoms  are  due  to  reduction  of  C02 
in  the  blood  (acapnia). 

Crile,4  as  a  result  of  extensive  experimentation,  has  elaborated  the 
vasomotor  theory  and  has  done  much  towards  explaining  the  basis  of 
shock.  His  experiments  seem  to  show  that  as  a  result  of  severe  mechan- 
ical injuries,  especially  painful  injuries,  also  as  a  result  of  profound 
psychic  influences  of  various  kinds,  impulses  are  conveyed  to  the  brain 
by  the  sensory  nerves.     These  afferent  impulses  are  assumed  to  be  the 

1  Circular  6,  Surgeon  General's  Office,  1864. 

2  Contributions  to  Medical  Research,  1903. 

3  Arch,  of  Int.  Med.,  1908,  i,  571. 

4  An  Experimental  Research  in  Surgical  Shock,  1899;  Crile  and  Lower,  Anoci  Asso- 
ciation, Philadelphia,  1914. 


102  SHOCK  AND  ALLIED  CONDITIONS 

primary  etiological  factor  in  the  development  of  shock,  whether  of  trau- 
matic shock  or  of  psychic  shod;.  These  impulses  through  their  effect 
upon  the  central  nervous  system  cause  disturbance  of  vasomotor  con- 
trol, embarrassment  of  respiration  and  diminution  or  arrest  of  the  heart 
action.  While  all  of  these  factors  are  present  in  cases  exhibiting  evi- 
dences of  a  considerable  degree  of  shock,  injuries  to  certain  regions 
of  the  body  seem  to  accentuate  one  or  more  of  the  factors;  for  example, 
injuries  to  the  interior  of  the  larynx  or  thoracic  cavity  may  cause 
instant  cessation  of  respiration;  injuries  to  the  male  genital  organs,  the 
pericardium  or  adjacent  portions  of  the  diaphragm  cause  irregularity, 
weakness,  or  arrest  of  the  heart  action;  while  irritation  of  the  perito- 
neum may  give  rise  to  marked  dilatation  of  the  splanchnic  vessels  and 
rapid  fall  of  blood-pressure. 

In  Crile's  experiments  it  was  found  that,  although  the  first  effect 
of  a  given  trauma  was  usually  a  transitory  rise  in  the  blood-pressure, 
after  repeated  applications  of  the  injuring  force  the  preliminary  rise 
did  not  occur,  but  a  progressive  and  permanent  lowering  of  the  blood- 
pressure  resulted.  Injury  to  certain  tissues,  as  the  interior  of  the 
larynx,  the  testicle,  and  certain  abdominal  viscera  were  often  followed 
by  a  rapid  fall  of  blood-pressure  without  the  preliminary  rise.  Crile 
has  assumed  that  some  change  occurs  in  the  vasomotor  centres  which 
results  in  an  abnormal  lowering  of  the  blood-pressure  and  that  this  is  an 
important  factor  in  shock. 

Crile's  experiments  also  show  that  the  integrity  of  the  circulation, 
that  is,  the  maintenance  of  the  blood-pressure,  depends  in  large 
measure  upon  the  regularity,  force  and  output  of  the  heart.  The  out- 
put of  the  heart  depends  upon  the  supply  of  blood  reaching  it  from  the 
vense  cava?;  this  supply  depends  upon  the  pressure  in  the  large  venous 
trunks;  the  venous  pressure  depends  upon  the  integrity  of  the  vaso- 
motor mechanism.  Thus,  any  agent  which  produces  vasomotor  paresis, 
diminished  pressure  in  the  large  venous  trunks  or  weakened  heart  action 
will  favor  the  development  of  a  vicious  cycle.  Under  such  conditions, 
comparatively  little  blood  is  in  circulation;  the  great  bulk  is  probably 
stored  in  the  venous  system.  As  a  result,  the  supply  of  oxygen  to  the 
tissues  undoubtedly  is  greatly  diminished,  and  the  effect  of  this  on 
the  central  nervous  system  presumably  is  to  produce  impairment 
or  cessation  of  all  its  functions. 

That  respiratory  changes  are  associated  with  lowered  blood-pressure 
is  apparent  in  many  of  Crile's  experiments.  Whenever  an  injury 
resulted  in  marked  lowering  of  blood-pressure  the  respiration  became 
shallow,  irregular  and  often  ceased  entirely.  In  90  out  of  103  experi- 
ments respiratory  failure  was  the  immediate  cause  of  death.  While 
the  belief  is  general  among  the  profession  that  in  shock  the  immediate 
cause  of  death  is  failure  of  the  heart,  Crile  considers  that  the  weak- 
ness of  the  heart  is  only  apparent  and  is  due  to  the  fact  that  the 
amount  of  fluid  brought  to  it  is  so  reduced  that  its  output  is  necessarily 
small,  and  that  its  rapid  action  is  an  effort  to  increase  this  output  and 


SHOCK 


103 


to  raise  the  blood-pressure.  This  view  is  substantiated  by  the  prompt 
improvement  in  the  action  of  the  heart  which  often  results  from  the 
administration  of  saline  infusion  intravenously. 

Morbid  Anatomy. — Concerning  the  pathological  changes  in  shock 
various  findings  have  been  reported:  Meltzer  states  that  there  are 
no  postmortem  changes  and  that  the  fatal  disturbances  underlying 
shock  are  exclusively  of  a  functional  nature.  This  is  the  view  held  by 
most  authorities.  On  the  other  hand  Crile1  reported  that  the  following 
conditions  were  found  at  autopsy  in  animals  which  had  died  as  a  result 
of  shock.  The  large  venous  trunks  were  full,  the  arteries  empty; 
the  splanchnic  veins  were  not  more  distended  than  the  somatic. 
The  left  ventricle  and  auricle  usually  contained  some  blood,  the  right 
ventricle  little  or  none.  The  lungs  were  anemic;  the  pulmonary 
vessels  empty.    The  liver,  spleen  and  kidneys  were  enlarged. 

It  has  been  claimed  by  some  that 
there  is  an  increase  in  the  specific 
gravity  of  the  blood.2 

Crile  and  Lower  have  recently 
reported  that  microscopical  exami- 
nation of  the  brains  of  dogs  in 
various  stages  of  shock  induced  by 
severe  traumatism  showed  "first, 
a  hyperactivity  characterized  by 
hyperchromatism  (marked  chromo- 
philic  properties  of  the  Xissl  bodies) ; 
later,  a  stage  of  exhaustion  char- 
acterized by  chromatolysis  (with 
disappearance  of  the  Nissl  bodies), 

disturbance  of  nucleus-plasma  relation,  rupture  of  nuclear  and  the  cell 
membranes  and  finally  disintegration.  These  changes  were  most 
marked  in  the  cortex  and  the  cerebellum  but  were  also  present  in 
the  medulla  and  the  cord.  They  state  that  the  cells  of  the  liver  and 
adrenals  show  corresponding  changes,  represented  by  generalized 
disappearance  of  the  cytoplasm.  On  the  basis  of  these  histological 
changes  Crile  has  founded  the  "Kinetic  Theory  of  Shock." 

The  Kinetic  Theory  of  Shock. — The  kinetic  theory  of  shock  postulates 
that  all  forms  of  shock  are  caused  by  overstimulation  and  consequent 
exhaustion;  that  the  cells  of  the  brain,  the  suprarenals,  and  the  liver 
show  physical  changes  corresponding  to  each  change  in  the  clinical 
cycle  of  shock;  and  that  these  cellular  changes  constitute  the  essential 
lesions  of  shock  and  are  caused  by  the  conversion  of  potential  energy 
into  kinetic  energy  at  the  expense  of  certain  chemical  compounds 
stored  in  the  affected  cells.  However,  it  has  not  been  shown  what 
relationship  exists  between  the  histological  changes  and  the  mani- 
festations of  shock  which  are  noted  clinically  and  experimentally.    In 


Fig.  37. — Changes  seen  in  brain  cells  of 
a  rabbit  subjected   to  fear.     Area  from 
cerebellum;      characteristic    changes     in 
Purkinje   cells   in  fright.       (From   Crile 
"Anoci-association.") 


1  Surgical  Shock,  Philadelphia,  1899.         2  Cf.  Vale,  Med.  Record,  1904,  Ixvi,  352. 


104  SHOCK  AND  ALLIED  CONDITIONS 

other  words  the  occurrence  of  the  cellular  changes  does  not  explain 
the  phenomena  of  shock. 

To  summarize:  Shock  is  dependent  upon  afferent  impulses  which 
may  be  excited  by  trauma,  psychic  influences  or  both;  these  impulses 
pass  to  the  central  nervous  system  and  cause  primarily  disturbance  of 
vasomotor  control,  embarrassment  of  respiration  and  diminution  or 
arrest  of  the  heart  action;  of  these  the  most  important  factor  is  the 
loss  of  vasomotor  control,  which  is  represented  by  lowered  blood- 
pressure.  With  the  clinical  manifestations  of  shock  are  associated 
certain  histological  changes  in  the  brain,  adrenals  and  liver. 

Etiology. — Shock  may  be  caused  by  any  agency  which  produces 
a  violent  impression  upon  the  central  nervous  system  through  the 
medium  of  the  nerves  of  sensation  or  special  sense;  violent  emotions 
have  frequently  been  observed  to  cause  syncope  and  even  death 
(psychic  shock).  Surgical  shock  in  the  great  majority  of  instances  is 
caused  essentially  by  bodily  injury  which  may  be  the  result  of  accident 
or  surgical  operation;  however,  psychic  influences  may  be,  and  fre- 
quently are,  associated  with  the  traumatic  and  may  act  as  accessories 
in  the  development  and  prolongation  of  shock. 

Regarding  the  conditions  which  favor  the  occurrence  of  shock,  it 
may  be  stated  that  lowered  vitality  from  any  cause,  and  an  abnormally 
impressionable  nervous  system,  are  conditions  in  which  a  severe 
degree  of  shock  may  be  expected.  Thus,  early  youth  and  old  age; 
malnutrition;  exhaustion  from  suffering,  prolonged  physical  effort  or 
insomnia;  uremia;  chronic  poisoning  from  alcohol,  drugs,  etc.,  are 
to  be  regarded  as  predisposing  factors.  Highly  impressionable  individ- 
uals, as  a  rule,  show  a  greater  reaction  to  slight  injuries  than  do  the 
more  phlegmatic,  and  in  such  persons  the  anticipation  of  injury  or 
pain  will  often  greatly  accentuate  the  resulting  impressions. 

Since  loss  of  blood  alone  will  produce  a  condition  very  similar  to 
shock,  it  is  evident  that  injuries  associated  with  a  considerable  degree 
of  hemorrhage  will  be  accompanied  by  more  profound  shock  than 
bloodless  injuries  of  the  same  extent  and  character. 

Certain  types  of  injury  produce  intense  shock,  notably  crushing 
injuries  and  extensive  burns.  Crile  has  shown  that  injury  or  even 
irritation  of  certain  regions  of  the  body  gives  rise  to  a  far  greater  degree 
of  shock  than  more  severe  trauma  elsewhere.  He  found  that  compara- 
tively slight  injury  to  the  mucous  membrane  of  the  larynx  produced 
sudden  cessation  of  respiration,  cardiac  inhibition,  and  a  rapid  decline 
in  the  blood-pressure,  even  when  the  animal  was  under  general  anes- 
thesia. After  division  of  the  superior  laryngeal  nerves  or  cocainiza- 
tion  of  the  parts  these  effects  were  not  apparent.  Direct  pressure  on 
the  heart,  pericardium,  and  great  vessels  produced  great  irregularity 
and  weakness  of  the  heart  and  a  lowering  of  blood-pressure.  Tapping 
the  under  surface  of  the  diaphragm  caused  marked  respiratory  dis- 
turbance and  cardiac  weakness.  Injuries  to  the  testicle  and  lung, 
pulling  upon  the  mesentery,  manipulation  of  the  parietal  peritoneum, 


SHOCK  105 

and  manipulations  in  the  region  of  the  pylorus,  gall-bladder  and  duo- 
denum, all  caused  an  exaggerated  degree  of  shock;  while  injuries  to 
the  pelvic  organs  (especially  in  the  female)  and  manipulation  of  the 
omentum  gave  rise  to  comparatively  little  disturbance.  Incisions 
or  wounds  in  the  skin  gave  rise  to  a  far  greater  degree  of  shock  than 
similar  injuries  to  the  muscles,  tendons,  fatty  tissues  and  fascia-. 
Injuries  to  or  even  traction  upon  nerve-trunks  was  accompanied  by 
considerable  systemic  disturbance;  while  injuries  to  the  bones  and 
large  joint-,  when  unaccompanied  by  injuries  to  the  nerves,  produced 
little  reaction.  When  the  animal  was  in  a  condition  of  shock  from 
repeated  trauma  or  had  recently  passed  through  such  a  condition,  it 
was  found  that  additional  injury,  even  of  moderate  degree,  was 
accompanied  by  a  further  lowering  of  the  blood-pressure.  This 
lowering  of  the  blood-pressure  was  wholly  out  of  proportion  to  the 
degree  of  the  injury,  and  the  reaction  from  it  was  much  delayed  or 
even  absent. 

The  depressing  influence  of  an  anesthetic  may  add  a  potent  factor 
which  is  accentuated  if  the  anesthetic  is  badly  administered.  Loss 
of  body  heat,  as  a  result  of  a  cold  operating  room,  exposure  of  the 
patient  or  of  the  viscera,  also  rough  handling  of  the  tissues,  especially 
the  abdominal  viscera,  likewise  favor  shock. 

In  general  it  may  be  stated  that  the  degree  of  shock  depend-  upon 
the  character  and  extent  of  the  injury,  its  location,  the  kind  of  tissues 
involved,  the  amount  of  hemorrhage,  and  the  temperament  and  mental 
condition  of  the  patient. 

Symptoms. — The  symptoms  of  shock  vary  with  the  site,  severity  and 
character  of  the  injury  and  with  the  susceptibility  of  the  patient. 
In  mild  cases  the  patient  complains  of  a  feeling  of  weakness,  slight 
nausea,  and  giddiness.  The  face  is  pale,  the  extremities  cold  and  often 
bathed  in  perspiration,  the  pulse  is  weak,  and  there  is  a  tendency  to 
syncope  if  the  patient  is  in  the  upright  position.  In  more  marked 
cases  there  may  be  a  temporary  loss  of  consciousness;  the  patient  is 
unable  to  sit  up,  lies  quietly,  and  takes  little  or  no  interest  in  his 
surroundings;  he  will  answer  questions;  does  not  complain  of  pain; 
and  evidently  wants  to  be  left  undisturbed.  In  the  severer  cases  con- 
sciousness is  almost  entirely  lost;  the  face  is  expressionless;  the  eyes 
are  fixed,  the  pupils  dilated  and  react  slowly  to  light;  there  is  no 
apparent  suffering  even  though  a  portion  of  the  trunk  is  extensively 
mangled  or  an  extremity  crushed.  The  surface  of  the  body  is  cold  and 
moist;  the  pulse  is  rapid,  irregular,  compressible  and  extremely  weak; 
respiration  is  rapid,  irregular,  shallow  and  gasping;  the  temperature 
is  subnormal;  the  sphincters  may  be  paralyzed;  the  patient  makes 
no  effort  to  move,  but  lies  in  any  position  in  which  he  is  placed.  Vomit- 
ing may  occur,  and  in  alcoholics  there  may  be  tremor  and  delirium. 
Exceptionally,  in  the  severest  cases,  restlessness  and  delirium  may  be 
the  most  prominent  symptoms  even  in  non-alcoholics.  A  low  blood- 
pressure  is  usual,  although  it  is  not  essential  to  the  production  of 


106  SHOCK  AND  ALLIED  CONDITIONS 

shock.1  (A.  R.  Short.2)  "In  a  series  of  experiments  in  which  blood 
counts  were  made  before  and  after  the  production  of  shock  it  was  found 
that  there  was  an  enormous  decrease  of  white  blood  cells  in  the  shocked 
animal."     (Mann.) 

To  summarize:  The  most  conspicuous  clinical  features  in  shock  are 
apathy,  pallor,  extreme  weakness,  cold,  moist,  clammy  skin,  diminished 
sensibility,  lowered  blood-pressure,  rapid,  weak,  and  irregular  pulse, 
rapid,  irregular,  and  shallow  respirations. 

Differential  Diagnosis. — Shock  and  hemorrhage  have  so  many  symp- 
toms in  common  that  it  is  often  difficult  to  make  a  differential  diag- 
nosis. The  question  may  be  a  serious  one,  especially  after  operations, 
as  it  is  most  important  to  know  whether  a  given  condition  of  weakness 
is  due  to  the  shock  of  operation  or  to  concealed  hemorrhage.  In  gen- 
eral it  may  be  said  that  in  shock  the  patient  is  weak  and  apathetic, 
while  in  hemorrhage  he  is  weak  and  restless.  Frequent  examinations 
of  the  blood  should  be  made  in  doubtful  cases;  a  progressive  diminu- 
tion of  hemoglobin  and  the  red  cells  indicates  hemorrhage. 

Prognosis. — The  prognosis  in  severe  shock  is  always  grave,  and  until 
there  is  a  decided  and  sustained  improvement,  the  outlook  should 
be  regarded  as  doubtful.  In  the  milder  cases  recovery  may  be  expected 
if  the  cause  of  the  depression  can  be  removed  and  appropriate  treat- 
ment can  be  carried  out.  Conditions  which  add  to  the  gravity  of  a 
given  case  are  the  combination  of  shock  with  hemorrhage,  anemia, 
delirium  tremens,  brain  injury,  arteriosclerosis,  or  a  heart  weakened 
by  chronic  valvular  disease,  myocarditis,  or  fatty  infiltration. 

Treatment. — The  treatment  wThich  is  usually  employed  for  shock 
has  been  based  chiefly  upon  clinical  observation  and  clinical  expe- 
rience. Recent  experimental  investigations,  however,  indicate  that 
the  long  accepted  methods  of  treatment  must  be  modified.  The 
suggested  modifications  of  the  usual  routine,  as  noted  below,  have 
been  outlined  by  Lieb. 

"Traumatic  shock  is  almost  always  complicated  by  more  or  less 
profound  psychic  shock.  Therefore,  the  first  indication  for  treatment 
is  to  numb  the  consciousness  of  the  patient  by  the  subcutaneous 
injection  of  morphine." 

The  patient  should  be  moved  as  gently  as  possible  and  hemorrhage 
should  be  controlled. 

"  If  possible  the  site  of  injury  should  be  physiologically  isolated  from 
the  central  nervous  system  by  blocking  afferent  nerves,  either  by  the 
injection  of  cocaine  around  the  area,  or  by  its  injection  into  a  nerve 
trunk.  Even  after  an  attempt  has  been  made  to  isolate  the  injured 
area,  manipulation  should  be  gentle,  because  complete  isolation  is 
difficult,  and  if  a  single  nerve  is  not  blocked  impulses  may  reach  the 
central  nervous  system  and  deepen  shock."  The  local  blocking  is 
indicated  even  when  general  anesthesia  is  employed." 

1  Mann,  Bull.  Johns  Hopkins  Hosp.,  1914,  xxv,  205;  Janeway  and  Ewing,  Annals  of 
Surgery,  1914,  lix,  158. 

2  The  Newer  Physiology  in  Surgical  and  General  Practice,  1914. 


SHOCK  107 

The  ideal  treatment  for  shock  has  been  shown  by  Crile  and  Lower 
to  be  the  direct  transfusion  of  blood.  This  should  be  employed  when 
possible  in  all  cases  with  low  blood-pressure.  However,  intravenous 
infusion  of  hot  normal  salt  solution  is  usually  depended  upon  as  the 
sheet  anchor  in  the  treatment.  The  infusion  should  be  given  slowly 
at  the  temperature  of  116°  to  118°  F.,  and  in  sufficient  quantity  to  pro- 
duce distinct  improvement  in  the  pulse  and  heart  action.  Repeated 
infusions  of  comparatively  small  quantities  apparently  have  a  better 
effect  than  a  single  large  infusion.  Adrenalin,  which  raises  the  blood- 
pressure,  is  often  administered  with  the  infusion.  About  1  to  \\  c.c. 
is  the  usual  dose;  1  c.c.  may  be  added  to  500  c.c.  of  salt  solution. 
A  better  method,  which  was  suggested  by  Crile,  is  to  thrust  the 
needle  of  a  hypodermic  syringe,  tilled  with  adrenalin  chloride  1  to 
1000,  through  the  rubber  tube  near  the  cannula  while  the  infusion 
is  being  given;  Crile  injects  1  to  2  c.c.  in  one  minute.  It  appears, 
however,  more  safe  and  more  effective  to  give  smaller  amounts,  for  in- 
stance, 0.3  c.c.  at  two-minute  intervals  for  four  or  five  doses.  Heiden- 
hain1  recommends  combining  pituitrin  with  the  adrenalin,  believing 
that  the  action  of  the  adrenalin  is  prolonged  and  rendered  more  effec- 
tive; they  are  given  intravenously,  0.6  c.c.  of  1  to  1000  adrenalin  and 
1  c.c.  of  pituitrin  being  added  to  one  litre  of  salt  solution.  Hypo- 
dermoclysis  is  sometimes  substituted  for  infusion  but  is  not  to  be 
recommended. 

Prior  to  the  transfusion  or  infusion  the  foot  of  the  bed  should  be 
raised  or  the  patient  placed  in  the  Trendelenburg  position.  The  use 
of  the  pneumatic  rubber  suit  was  recommended  by  Crile  to  drive  the 
blood  from  the  extremities  and  trunk  into  the  brain,  but  it  is  rarely 
used.  The  same  object  may  be  accomplished  more  simply  by  bandag- 
ing the  extremities. 

Drugs. — A  variety  of  drugs,  especially  stimulants,  have  been  recom- 
mended for  the  treatment  of  shock  and  are  in  general  use.  Thus, 
atropine  and  small  doses  of  strychnine  are  given  hypodermically; 
atropine  to  prevent  the  inhibitory  vagal  influence  which  has  been  sup- 
posed to  be  present  in  shock,  strychnine  for  its  action  on  the  heart- 
muscle  and  vasomotor  centres.  Whisky  is  administered  by  the  mouth, 
hypodermically,  or  by  the  rectum;  when  given  by  the  bowel,  it  is 
often  combined  with  hot  coffee.  Other  stimulants,  such  as  camphor, 
caffeine,  ether  and  digitalis  are  employed  hypodermically.  Since  a 
low  blood-pressure  is  one  of  the  most  important  elements  in  shock, 
the  use  of  nitroglycerin,  or  other  vasomotor  dilators  is  generally 
condemned. 

On  the  basis  of  extensive  experimentation,  Lieb  offers  the  following 
criticisms  of  the  use  of  drugs.  "  Drug  treatment  is  not  usually  effective. 
Strychnine  is  contraindicated.  It  acts  chiefly  on  the  spinal  cord  and 
by  opening  up  new  paths  for  the  transmission  of  impulses  tends  to 

1  Deutsch.  Zeitsch.  f.  Chir.,  1914,  cxxvii,  202. 


108  SHOCK  AND  ALLIED  CONDITIONS 

magnify  the  effect  of  each  afferent  stimulus.  The  object  of  treatment 
should  be  to  block,  not  to  facilitate  the  transmission  of  impulses. 
Caffeine,  whether  as  the  pure  alkaloid  or  in  the  form  of  coffee,  is 
also  to  he  avoided.  On  the  eord  it  acts  like  strychnine;  in  addition, 
it  stimulates  the  higher  cerebral  centres,  and  by  arousing  the  patient 
to  more  complete  consciousness  adds  psychic  shock  to  traumatic. 
Whiskey,  camphor,  tincture  digitalis,  or  ether  given  subcutaneously 
produce  marked  local  irritation,  that  is,  they  cause  pain.  Since  pain 
is  one  of  the  chief  causes  of  shock  the  injection  of  irritants  or  pain- 
producing  drugs  under  the  skin  increases  the  exciting  cause  and  should 
be  avoided. 

It  must  be  repeated  that  the  central  nervous  system  should  be 
guarded  against  afferent  stimuli;  therefore,  unless  it  is  urgently  indi- 
cated, no  irritant  drug  should  be  employed  by  inhalation,  by  mouth,  by 
rectum,  subcutaneously,  or  by  any  other  channel  of  administration. 

Summary  of  Treatment. — Morphine  should  be  given  to  desensitize 
the  patient;  body  heat  should  be  conserved;  the  site  of  injury  should 
be  blocked  from  the  central  nervous  system;  the  blood-pressure 
should  be  raised  and  the  volume  of  the  blood  increased,  preferably 
by  transfusion,  otherwise  by  intravenous  saline  infusions  with  adre- 
nalin. Stimulants  which  act  upon  the  central  nervous  system  are  for 
the  most  part  useless  and  may  be  harmful.  They  should  be  em- 
ployed only  in  cases  of  extreme  shock  in  which  death  seems  imminent 
and  immediate  stimulation  is  imperative  while  other  means  of  treat- 
ment are  under  preparation. 

Prophylaxis. — In  general,  surgical  operations  should  not  be  under- 
taken during  a  condition  of  severe  shock.  To  this  rule,  however,  there 
are  many  exceptions;  hemorrhage  must  be  controlled,  certain  penetrat- 
ing wounds  of  the  thorax  and  abdomen  must  be  explored,  strangulated 
hernias  must  be  relieved,  etc.  Under  such  conditions,  when  general 
anesthesia  is  necessary,  nitrous  oxide  and  oxygen  or  ether  should  be 
employed,  preceded  by  a  hypodermic  injection  of  morphine  and  atro- 
pine. An  intravenous  saline  infusion  may  be  begun  when  the  patient 
is  under  the  anesthetic.  Elaborate  preparation  of  the  wound  area 
should  not  be  undertaken  in  cases  with  infection  well  established. 
The  anesthesia  should  be  smooth  and  even;  an  overdose  of  the  anes- 
thetic causes  a  fall  in  blood-pressure  which  predisposes  to  shock. 
The  operation  should  be  rapid,  the  manipulations  gentle,  dissections 
clean  cut,  hemostasis  thorough  and  the  exposure  of  cut  surfaces  and 
viscera  reduced  to  a  minimum. 

In  undertaking  operations  where  from  the  nature  of  the  operation 
or  the  condition  of  the  patient  considerable  shock  is  to  be  expected, 
certain  precautions  should  be  observed.  If  delay  is  possible  the  con- 
dition of  the  patient  should  be  rendered  as  favorable  as  possible  by 
rest,  food,  free  administrations  of  fluids,  etc.  The  operating  room 
should  be  warm  and  the  anesthetizing  room  quiet.  A  preliminary 
hypodermic  of  morphine  should  be  given,  especially  in  nervous  and 


FAT-EMBOLISM  109 

apprehensive  individuals.  It  is  of  advantage  to  operate  at  a  time 
when  a  patient  is  in  the  best  physical  condition  to  withstand  depres- 
sing influences.  Generally  speaking,  patients  are  at  their  best  in  the 
early  part  of  the  day.  The  general  precautions  mentioned  above  in 
regard  to  anesthesia  and  operative  teehnie  should  be  carefully 
observed.  Harvey  dishing  has  emphasized  the  importance  of  watch- 
ing the  blood-pressure  during  operations  which  are  likely  to  be  accom- 
panied by  severe  shock,  as  variations  in  pressure  are  far  more  significant 
in  indicating  shock  than  changes  in  the  pulse  rate. 

In  connection  with  the  prevention  of  operative  shock,  Crile  attaches 
much  importance  to  anoci  association,  the  principle  of  which  is  "the 
exclusion  of  all  harmful  stimuli,  making  the  brain  and  the  personality 
of  the  patient  unmodified  and  unimpaired  through  the  operation." 
He  advances  the  theory  that  the  exclusion  of  both  traumatic  and 
emotional  stimuli  will  wholly  prevent  the  shock  of  operation.  In  the 
application  of  anoci  association,  psychic  influences,  such  as  ante- 
operative  anxiety  and  excitement  are  minimized  by  the  administra- 
tion of  morphine  and  scopolamine  before  the  operation;  operative 
unrest  and  physical  suffering  are  eliminated  by  the  employment  of 
general  anesthesia.  Crile  recommends  nitrous  oxide  and  oxygen. 
In  very  impressionable  patients,  such  as  those  having  exophthalmic 
goitre,  Crile  attempts  to  perform  the  operation  without  the  patient's 
knowledge — "to  steal  the  gland."  He  believes  that  ether  and  other 
general  anesthetics  do  not  break  the  afferent  paths  for  stimuli  from  the 
seat  of  injury  and  offer  no  protection  to  the  brain  cells  against  the 
effect  of  operative  trauma.  In  order  to  prevent  impulses  from  the 
field  of  operation,  the  division  of  tissues  is  preceded  by  complete  local 
blocking  through  circumferential  injections  of  novocain.  Before 
closing  the  wound  quinine  and  urea  hydrochloride  is  injected  around 
the  whole  exposed  field  in  order  that  afferent  impulses  may  be 
prevented  for  several  days  after  the  operation. 


FAT-EMBOLISM. 

As  a  result  of  fractures  and  other  traumata  small  globules  of  fat 
may  enter  the  blood  current  and  be  carried  to  the  lungs.  These  fat 
globules  may  plug  the  pulmonary  capillaries  or  be  forced  through  the 
lungs  and  be  deposited  in  the  brain,  kidneys,  spleen,  coronary  arteries, 
and  other  tissues. 

Almost  all  cases  of  fat-embolism  occur  in  connection  with  the  sur- 
gery of  the  bones  and  joints,  that  is,  in  connection  with  fractures, 
the  manipulation  of  contracted  joints  and  operations  upon  bones. 
It  is  generally  believed  that  the  fat  enters  directly  into  ruptured 
veins  of  the  bone  marrow,  but  Ribbert  considers  that  the  fat  droplets 
may  be  taken  up  by  the  lymphatics.  The  use  of  the  Esmarch  bandage 
in  bone  operations  has  been  said  to  predispose  to  embolism  by  favoring 


110  SHOCK  AND  ALLIED  CONDITIONS 

the  sudden  admission  of  fat  into  the  circulation  on  the  removal  of  the 
bandage. 

Most  cases  occur  after  the  age  of  fourteen,  according  to  v.  Aberle.1 
He  considers  that  the  explanation  lies  in  the  peculiarities  of  the  devel- 
opment of  the  bone  marrow.  Infantile  shaft  bones,  in  the  first  years 
of  life  contain  only  red  marrow,  very  poor  in  fat;  whereas  after  about 
the  fourteenth  year  the  marrow  of  the  shaft  bone  usually  consists 
essentially  of  fat.  Fat-embolism  is  noted  relatively  frequently  follow- 
ing the  manipulation  of  joints  which  present  marked  contractions  and 
atrophic  bones,  such  as  may  follow  poliomyelitis  and  rheumatism. 
This  predominant  occurrence  of  fat  embolism  with  injury  to  atrophic 
bones  is  explained  by  the  fact  that  in  atrophy  the  solid  osseous 
substance  that  is  lost  is  largely  replaced  by  fat.  The  main  factors, 
therefore,  in  these  cases  are  the  more  or  less  advanced  osteoporosis 
and  the  presence  of  yellow  fat  marrow.  Under  such  conditions  fat- 
embolism  results  from  the  fracture  and  compression  of  the  osteoporotic 
bone. 

Grondahl  has  recently  discussed  the  occurrence  of  fat-embolism 
after  injury  to  the  soft  parts  and  internal  organs,  about  which  very 
little  has  been  published.  His  collected  cases  include  36  injuries  to 
the  subcutaneous  tissues,  through  knife-thrusts  and  operative  wounds. 
Some  of  the  patients  died  soon  after  the  surgical  intervention,  some 
survived  from  one  to  ten  days.  The  operations  were  of  almost  all 
varieties,  including  the  thoracic  and  abdominal  cavities,  but  there 
were  no  operations  involving  tissues  which  contain  an  excessive  amount 
of  fat,  such  as  the  breast. 

Symptoms. — The  clinical  picture  of  fat-embolism  is  a  complex  of 
the  symptoms  due  to  involvement  of  the  different  organs;  it  varies 
with  the  degree  to  which  each  is  affected.  The  symptoms  due  to  in- 
volvement of  the  lungs  predominate  as  a  rule.  The  symptoms  and 
signs  which  result  from  pulmonary  emboli  are  dyspnea,  cyanosis, 
expectoration  of  frothy  blood-stained  sputum  and  signs  of  pulmonary 
edema.  Emboli  lodged  in  the  brain  may  give  rise  to  restlessness,  con- 
vulsions, delirium,  and  somnolence;  in  a  very  few  cases  focal  symptoms 
have  been  reported.  The  patient's  condition  may  suggest  meningitis. 
If  emboli  become  lodged  in  a  coronary  artery  the  heart  action  is 
seriously  affected;  the  pulse  becomes  rapid  and  thready;  sudden 
arrest  of  the  heart  may  occur.  Fat-emboli  in  the  spleen  and  kidneys 
are  not,  as  a  rule,  associated  with  significant  symptoms;  hematuria 
appears  to  be  of  exceptional  occurrence;   but  severe  pain  in  the  back 

1  Ueber  Fettembolie  nach  orthopaedischen  Operationen,  Zeitschrift  f.  orthopaedische 
Chirurgie,  1908,  xix,  89;  Gangele,  Ueber  Fettembolie  und  Krampfanfalle  nach  ortho- 
paedischen Operationen,  Zeitschrift  f.  orthopaedische  Chirurgie,  1914,  xxxiv,  193; 
Grondahl,  Untersuchungen  iiber  Fettembolie,  Deutsche  Zeitschrift  f.  Chirurgie,  1911, 
iii,  56;  Schanz,  Zur  Behandlung  der  Krampfanfalle  nach  orthopaedischen  Operationen, 
Centralblatt  f.  Chir.,  1910,  No.  2,  43;  Wierzejenski.  Ueber  Unfalle  und  Komplikationen 
bei  orthopaedischen  Operationen,  Verhandlg.  d.  Deutsch.  Ges.  f.  Orthopaed.  Chir.  X 
Congress,   1910. 


STATUS  LYMPHATICUS  111 

is  often  ascribed  to  renal  emboli.  With  fat-embolism  free  fat  may  be 
found  in  the  urine,  and  ecchymotic  spots  may  occur  in  the  skin, 
mucous  membranes  and  conjunctiva?.  The  temperature  is  usually 
slightly  elevated  or  subnormal;  if  there  is  a  marked  rise  pneumonia 
should  be  suspected. 

The  symptoms  usually  do  not  begin  until  the  second  to  the  fourth 
day  after  the  fracture,  operation  or  other  surgical  intervention,  such 
as  change  of  fixation  dressing;  but  occasionally  they  make  their 
appearance  immediately.  The  symptoms  may  be  extremely  mild 
and  the  true  condition  may  readily  pass  unrecognized;  in  fact  it  is 
generally  believed  that  fat-embolism  may  occur  without  giving  rise 
to  any  symptoms.  In  cases  of  moderate  severity  spontaneous  recovery 
is  the  rule.  In  severe  cases  somnolence  and  coma  usually  develop 
and  death  may  ensue;  but  in  some  cases  of  the  pulmonary  type  with 
signs  of  extreme  edema  of  the  lungs  consciousness  may  be  retained 
almost  to  the  time  of  death.    Sudden  death  occasionally  occurs. 

Treatment. — It  is  important  to  recognize  the  factors  which  favor 
the  occurrence  of  fat-embolism  and  to  exercise  extreme  care  under 
these  conditions  in  manipulations  and  operations  upon  the  bones  and 
joints. 

Immediate  treatment  should  consist  in  absolute  rest  of  the  injured 
part  and  cardiac  stimulants  as  indicated.  Amy]  nitrite  and  the 
inhalation  of  oxygen  have  been  recommended.  Schanz,  Gangele, 
and  others  consider  that  the  proper  method  of  treatment  of  fat-embo- 
lism is  immediate  and  frequently  repeated  administrations  of  salt  solu- 
tion subcutaneously  or  intravenously  in  order  to  dislodge  the  emboli. 
It  appears  questionable  whether  this  method  is  reallv  effective.  If  it  is 
effective  there  is  risk  that  the  displaced  emboli  will  become  lodged 
elsewhere  and  prove  equally  serious.  However,  the  advocates  of  the 
method  claim  that  it  has  repeatedly  been  proved  to  be  efficient; 
moreover,  the  chances  are  good  that  dislodged  emboli  will  come  to 
rest  in  relatively  harmless  positions.  Therefore,  the  method  appears 
justifiable  in  the  presence  of  serious  symptoms. 

STATUS   LYMPHATICUS. 

Status  lymphaticus  is  a  condition  of  lowered  resistance  associated 
with  certain  changes  in  the  lymphoid  tissues,  and  characterized, 
especially  in  adolescence  and  adult  life,  by  more  or  less  well  defined 
physical  peculiarities.  The  chief  importance  of  the  condition  is  due 
to  the  marked  susceptibility  of  infants  and  children  of  this  type  to 
infectious  diseases,  especially  tuberculosis.  Of  vital  importance  to 
the  surgeon  is  the  fact  that  individuals  presenting  status  lymphaticus 
often  die  suddenly  and  unexpectedly  during  an  operation. 

Efforts  have  been  made,  with  some  success  to  differentiate  anatomic- 
ally and  clinically  between  conditions  dependent  upon  (1)  the  thymus 
alone  (status  thymicus),  (2)  the  general  lymphatic  tissues  exclusive 


112  SHOCK   AND   ALLIED   CONDITIONS 

of  the  thymus  (status  lymphaticus),  and  (3)  those  dependent  upon 
both  the  thymus  and  the  general  lymphatic  tissue-  (status  thymico- 
lymphaticus. We  will  not  attempt  to  differentiate  between  these 
subdivisions,  but  will  consider  them  collectively  under  the  general 
term  'Status  lymphaticus." 

Status  lymphaticus  was  first  described  by  Paltauf,1  and  for  many 
years  it  was  supposed  to  lie  of  very  exceptional  occurrence.  At  present, 
however,  it  is  noted  not  infrequently.  Undoubtedly  many  cases 
were  formerly  overlooked  both  clinically  and  at  autopsy. 

There  appears  to  be  in  some  cases  a  family  predisposition  to  status 
lymphaticus.  There  is  reason  to  believe  that  maternal  tuberculosis 
and  syphilis  are  of  etiological  importance. 

Morbid  Anatomy. — Persistence  of  the  thymus  is  a  frequent  and 
significant  feature:  histologically,  the  thymus  presents  simple  hyper- 
plasia of  the  lymphoid  cells.  There  is  also  hyperplasia  of  the  lymph 
nodes,  especially  the  cervical,  tracheobronchial  and  mesenteric,  and 
hyperplasia  of  the  lymphoid  tissue  of  the  fauces,  tongue,  pharynx, 
digestive  tract  and  spleen.  In  many  cases  there  is  hypoplasia  of  the 
aorta  and  of  the  genital  organs.  Other  changes  have  been  reported, 
for  instance,  excentric  left  sided  cardiac  hypertrophy  and  hypoplasia 
(if  the  chromaffin  system.     (Hedinger.)2 

Symptoms. — The  symptoms  and  objective  signs  have  been  summar- 
ized by  Emerson  as  follows:  In  man  there  is  scantiness  of  hair  on 
the  chin  and  upper  lip,  -canty  axillary  and  sternal  hair,  scanty  or 
feminine  distribution  of  the  pubic  hair;  slender  thorax;  rounded 
contour  of  the  upper  arms  and  thighs  with  an  arching  of  the  latter; 
hypoplastic  external  genitals  and  a  delicate  velvety  skin.  Less  con- 
stantly there  i>  found  hyperplasia  of  the  lymphoid  tissue  of  the  nose, 
throat  and  tongue  and  an  increase  in  the  palpable  superficial  lymph 
nodes,  especially  the  cervical  and  axillary  nodes.  Emerson  considers 
that  the  following  features  are  so  inconstant  as  to  be  of  little  value 
in  arriving  at  a  diagnosis;  the  character  of  the  hair  of  the  head,  which 
is  supposed  to  be  commonly  coarse  and  straight  in  status  cases;  slender 
columnar  neck,  rounded  feminine  abdomen  and  enlargement  of  the 
spleen. 

In  women  the  features  to  emphasize  in  status  lymphaticus  are  the 
peculiar  character  of  the  skin  of  the  body  and  extremities,  the  scanti- 
ness of  the  axillary  hair  pad,  the  scantiness  of  pubic  and  perineal  hair 
and  hypoplasia  of  the  genital  apparatus.  Some  women  of  decided 
status  conformitv  have  a  marked  growth  of  hair  on  the  face  and  upper 

In  infants  there  are  frequently  no  symptoms  nor  physical  signs  to 
suggest  the  existence  of  status  lymphaticus.  But  many  of  these  cases 
suffer  from  attacks  of  laryngospasm  with  convulsive  movements,  show 
enlargement  of  the  tonsils,  spleen  and  superficial  lymph  nodes  and 

Wii  b.  klin.  Wchnschr.,  L889,  ii.  ^77. 
-  KorrespondenzbJatt  f.  Schweizer  Aerate,  1907,  X".  Hi,  521. 


ST  A  T  US  L  YM  PHA  TIC  US  113 

present  complications,  such  as  eczema  and  changes  in  the  bones 
resembling  rickets.  Moreover,  children  of  this  type  are  usually  pale 
and  pasty  in  appearance  and  often  show  marked  adiposity. 

"Both  children  and  adults  with  status  lymphaticus  are  especially 
apt  to  die  (suddenly)  from  slight  external  causes,  such  as  shock,  im- 
mersion in  cold  water,  local  or  general  anesthesia,  during  the  course  of 
infectious  diseases,  and  following  injections  of  diphtheria  antitoxin 
(and  salvarsan)."     (Cocks.) 

Operative  Deaths. — The  majority,  but  not  all,  of  the  operative 
deaths  have  followed  the  use  of  chloroform.  Death  may  occur  at  any 
stage  of  the  anesthesia,  or  after  the  patient  apparently  has  recovered 
from  its  effects.  McCardie1  has  described  the  manner  of  death  as  it 
occurred  in  reported  cases:  "In  certain  of  them  facial  pallor  and  di- 
lated pupils  were  first  noticed  and  then  it  was  found  that  cardiac  action 
had  stopped.  In  others  respiration  was  observed  to  become  superficial 
and  intermittent  and  at  the  same  time  the  pulse  was  impalpable;  in 
yet  others  cyanosis  first  appeared  together  with  dyspnea,  the  circula- 
tion quickly  failing  afterwards.  In  another  type  of  case  there  was 
sudden  failure  of  circulation  and  respiration,  apparently  simulta- 
neously." The  age  of  the  patients  in  McCardie's  series  was  from  six 
months  to  fifty-five  years. 

Diagnosis. — The  recognition  of  the  existence  of  status  lymphaticus 
is  of  vital  importance  when  an  operation  is  under  consideration.  A 
history  of  one  or  more  sudden  unexplained  deaths  in  other  members 
of  the  patient's  family,  or  attacks  of  stridulous  breathing  or  severe 
dyspnea  during  the  first  year  of  life  should  cause  careful  investigation 
for  evidences  of  status  lymphaticus.  In  adults  the  clinical  manifes- 
tations can  usually  be  recognized  readily.  In  infants  a  definite  diag- 
nosis is  more  difficult  and  is  largely  dependent  upon  the  recognition 
of  enlargement  of  the  thymus.  This  is  aided  by  percussion,  z-rays  and 
tracheoscopy.  Percussion,  according  to  Jacobi,  should  be  made  with 
the  child  held  face  downward.  The  dulness  of  the  thymus  corre- 
sponds to  a  triangular  area  with  base  above,  approximately  at  the  level 
of  the  sternoclavicular  articulation,  the  rounded  apex  being  on  the 
plane  of  the  second  costal  cartilage  or  lower.  In  some  cases  enlarge- 
ment of  the  thymus  may  be  demonstrated  by  skiagraphy;  tracheo- 
scopy will  demonstrate  the  presence  of  thymic  stenosis,  but  is  a  dan- 
gerous procedure  in  these  cases. 

Treatment. — Since  lesions  of  the  lymphoid  tissues  are  frequently 
associated  with  status  lymphaticus  or  lymphatism,  hypertrophied 
tonsils,  adenoids  and  tuberculous  lymph  nodes  are  often  found  in 
children  of  this  type.  Individuals  who  show  definite  indications  of  a 
status  condition  should  not  be  subjected  to  operation  unless  operation 
is  imperative.  Operations  should  be  performed  under  local  anesthesia 
or  under  carefully  administered  ether  anesthesia,  never  under  chloroform. 

1  Status  Lymphaticus  and  General  Anesthesia,  British  Med.  Jour.,  1908,  19G. 
8 


114  SHOCK  AND  ALLIED  CONDITIONS 

For  thymic  asthma  with  marked  dyspnea  due  to  enlargement  of  the 
thymus,  thymectomy  is  at  times  indicated.  It  has  proved  efficient 
in  a  number  of  cases.1 

SURGICAL   RISK   IN   ALCOHOLICS. 

The  habitual  consumption  of  alcohol  markedly  increases  the  risk  of 
an  operation.  The  risk  is  much  greater  in  the  chronic  tippler  than  in 
one  who  occasionally  indulges  to  excess. 

Following  the  prolonged  use  of  alcohol  serious  organic  changes 
occur,  for  example,  arteriosclerosis,  cirrhosis  of  the  liver,  myocarditis 
and  nephritis.  As  a  result  of  chronic  lesions  of  this  kind  the  diseased 
organs  are  frequently  seriously  affected  by  operations  under  general 
anesthesia.  Suppression  of  urine,  uremia,  cardiac  weakness,  etc.,  may 
result.  Although  in  a  large  proportion  of  cases,  chronic  alcoholism  pro- 
duces in  the  various  organs  the  pathological  changes  which  favor  the 
development  of  such  postoperative  complications,  alcoholism  is  not 
always  the  cause.  Therefore,  these  complications  will  be  discussed 
under  separate  headings,  in  the  consideration  of  the  organs  with 
which  they  are  connected. 

There  are,  however,  certain  operative  dangers  and  serious  sequelae 
which  are  definitely  and  immediately  dependent  upon  chronic 
alcoholism. 

The  administration  of  a  general  anesthetic  to  a  chronic  alcoholic 
is  not  only  difficult  but  it  is  dangerous.  Alcoholics  require  a  large 
amount  of  ether  to  secure  proper  relaxation;  they  usually  breathe 
badly  and  cyanosis  supervenes  rapidly.  As  a  result  of  the  dilatation 
of  the  vessels  hemorrhage  from  the  operative  wound  is  increased. 

Postoperative  delirium  tremens  and  pneumonia  are  of  frequent 
occurrence. 

Alcoholics  do  not  respond  to  stimulants  as  well  as  non-alcoholics; 
large  doses  are  required,  and  even  these  are  usually  less  effective 
than  smaller  doses  in  non-alcoholic  individuals. 

The  resistance  of  the  tissues  to  infection  appears  to  be  diminished 
by  chronic  alcoholism. 

Before  operations  are  undertaken  upon  alcoholic  patients,  a  preliminary 
course  of  treatment  should  be  enforced  if  possible;  such  a  coarse  will 
do  much  towards  the  prevention  of  delirium  tremens.  Operation 
should  be  delayed  from  two  days  to  about  two  weeks.  Alcohol  should 
be  gradually  withdrawn;  adequate  sleep  should  be  secured,  if  neces- 
sary by  hypnotics,  such  as  bromides  or  paraldehyde;  simple  food  should 
be  taken  frequently  and  in  abundance;  the  bowels  should  be  moved 
freely  and  regularly  and  warm  baths  should  be  given  regularly.  Before 
operation  morphine  and  atropine  should  be  administered  to  quiet  the 
patient  and  to  lessen  the  amount  of  anesthetic  required. 

1  Cf.  Parker,  Surgery  of  the  Thymus  Gland,  Amer.  Jour.  Diseases  of  Children,  1913, 
v,  89. 


SURGICAL  RISK  IN  ALCOHOLICS  115 

Delirium  Tremens. — The  shock  of  injury  or  operation  not  infre- 
quently acts  as  the  exciting  cause  of  an  attack  of  delirium  tremens 
in  an  individual  predisposed  to  this  condition  l>y  chronic  alcoholism. 
The  condition  rarely  occurs  in  periodic  drinkers,  hut  rather  in  those 
who  regularly  consume  a  considerable  amount  of  alcohol  each  day. 
It  follows  the  use  of  whiskey  more  frequently  than  of  wine  or  beer. 
The  sudden  withdrawal  of  alcohol  in  a  person  addicted  to  its  use  seems 
to  precipitate  the  attack  in  some  cases. 

Symptoms. — The  onset  of  the  attack  is  usually  from  one  to  three 
days  after  the  operation  or  accident.  It  is  characterised  by  extreme 
irritability,  restlessness,  sleeplessness  and  persistent  incoherent  talk- 
ing, although  the  patient  may  give  intelligent  answers  to  questions. 
There  is  marked  tremor  of  the  ringers,  lips,  and  tongue.  The  bowels 
are  constipated;  the  appetite  is  poor.  If  the  attack  progresses,  the 
patient  develops  delusions  of  persecution,  sees  strange  animals,  insects, 
serpents,  and  other  reptiles  about  him  and  in  his  bed.  He  makes 
violent  efforts  to  rid  himself  of  these,  and  calls  upon  his  attend- 
ants for  assistance.  He  tries  to  get  out  of  bed  and  loudly  abuses  a 
nurse  or  attendant  who  attempts  to  restrain  him.  There  are  marked 
tremor,  profuse  perspiration,  evidences  of  extreme  fright,  and  of  acute 
mental  and  physical  sufferings.  Yet,  in  spite  of  constant  efforts  to 
get  out  of  bed  and  to  resist  those  who  are  restraining  him,  there  is 
no  evidence  of  pain  in  the  injured  part,  which  is  often  used  vigorously. 
The  pulse  becomes  rapid  and  feeble  and  the  patient  exhausted.  The 
urine  usually  contains  considerable  albumin.  The  exhaustion  which 
follows  the  violent  efforts  may  result  in  syncope  and  sudden  death,  or 
coma  may  supervene  and  death  follow  at  a  later  period.  Not  infre- 
quently complications  develop,  especially  pneumonia.  The  mortality 
of  postoperative  delirium  tremens  has  been  placed  as  high  as  50  per 
cent.;  the  death  rate  is  decidedly  higher  than  when  delirium  tremens  is 
unassociated  with  injury.  If  the  outcome  of  the  attack  is  favorable 
after  about  two  to  four  days,  in  uncomplicated  cases,  the  exhausted 
patient  falls  into  a  deep  sleep;  on  awakening  he  feels  weak  and  tired; 
his  mind  is  clear  but  he  has  little  or  no  recollection  of  what  has  occurred. 

Treatment. — The  treatment  of  delirium  tremens  should  begin  as 
early  as  possible.  The  essential  factors  are  food  and  sleep.  An  abun- 
dance of  simple  food  should  be  given  frequently  and  regularly.  Milk. 
eggs  and  beef  preparations  are  to  be  recommended.  To  induce  quiet 
and  sleep  sedatives  must  be  given  freely  until  the  desired  effect  is 
obtained.  Sodium  bromide  often  acts  well,  especially  early  in  the 
attack;  paraldehyde  is  of  value  since  it  acts  quickly,  although  the 
effect  is  not  lasting;  moreover,  it  may  increase  the  excitability  and 
delirium.  It  may  be  given  by  mouth,  oj~iv>  or  by  rectum  in  larger 
doses.  Drugs  that  act  more  slowly,  such  as  sulphonal,  gr.  x,  may  be 
combined  with  paraldehyde  to  advantage.  Numerous  other  hypnotics, 
as  veronal,  trional  and  chloral  have  been  recommended.  Chloral  is 
often  combined  with  bromides.    When  patients  refuse  to  swallow,  the 


116  SHOCK  AND  ALLIED  CONDITIONS 

hypodermic  injection  of  £  grain  of  morphine  with  T^(7  grain  of  scopo- 
lamine or  hyoscin  hydrobromide  will  be  found  useful,  also  hyoscin 
hydrobromate  in  doses  of  T^  to  y1-  grain.  The  liberal  use  of  alcohol  is 
usually  recommended  early  in  the  attack;  alcohol  administered  after 
the  symptoms  have  fully  developed  certainly  has  no  effect  on  the 
duration  of  the  disease.  Nevertheless,  in  many  cases  the  asthenic 
condition  of  the  patient  indicates  the  use  of  stimulants.  Under  these 
conditions,  alcohol  may  be  effective,  or  other  cardiac  stimulants  may 
be  necessary.  Cold  baths  or  packs  and  repeated  and  prolonged 
lukewarm  baths  have  been  used  with  satisfactory  results.  They  have 
a  sedative  effect,  induce  sleep  and  at  times  do  away  with  the  need  of 
narcotics.  The  bowels  should  be  carefully  regulated;  an  initial  dose 
of  calomel  is  advisable.  When  a  patient  is  so  restless  as  to  need  con- 
stant restraint  he  should  be  secured  by  a  jacket  or  by  folded  sheets 
attached  to  the  bed,  but  care  should  be  taken  lest  the  respiratory 
movements  be  interfered  with. 

Prophylaxis. — Prophylactic  measures  should  be .  employed  after 
injury  or  operation  in  those  who  are  predisposed  to  delirium  tremens. 
The  liberal  use  of  alcohol  is  advisable;  food  should  be  given  frequently 
and  in  abundance;  sleep  should  be  induced  by  narcotics,  such  as 
bromides;  the  bowels  should  be  moved  freely  and  regularly,  and 
fluids  should  be  administered  by  rectum  or  by  hypodermoclysis  to 
favor  free  elimination  through  the  skin  and  kidneys. 

ACIDOSIS. 

The  term  acidosis  was  introduced  by  Naunyn  to  define  a  clinical 
condition  which  was  supposed  to  be  dependent  upon  the  accumulation 
of  acids  in  the  body  in  sufficient  quantity  to  interfere  with  normal 
metabolism. 

The  usual  explanation  of  acidosis  is  dependent  upon  the  following 
interpretation  of  certain  chemical  changes  which  there  is  reason  to 
believe  occur  in  the  human  body.  The  complete  oxidization  of  fats 
normally  results  in  water  and  carbon  dioxide.  Incomplete  oxidiza- 
tion of  fats  leads  to  the  formation  of  fatty  acids  among  which  are  B. 
oxybutyric  acid  and  diacetic  acid,  which  further  oxidization  converts 
into  acetone.  Fatty  acids  thus  produced  are  neutralized  by  the  alka- 
line bases,  ammonia,  sodium,  potassium,  calcium,  etc.,  which  combine 
with  the  fatty  acids.  These  bases  are  derived  from  the  blood  to  a  con- 
siderable extent  and  the  alkalinity  of  the  blood  is  lowered  in  proportion 
to  the  diminution  of  its  bases.  The  unneutralized  fatty  acids  and  the 
salts  of  diacetic  acid  are  toxic. 

The  work  of  Emden  and  others  suggests  that  the  liver  plays  a  part 
in  the  intermediary  katabolism  of  fats  and  that  certain  unpaired  con- 
ditions of  the  liver  or  its  blood  supply  cause  interference  with  the 
complete  oxidization  of  fats  and  therefore  favor  the  formation  of 
fatty  acids. 


ACIDOSIS  117 

The  energy  of  the  body  is  derived  largely  from  the  oxidization  of 
carbohydrates;  if  carbohydrates  are  insufficiently  supplied  to  the  body 
either  as  a  result  of  deficiency  of  ingested  carbohydrates  or  imperfect 
absorption  or  assimilation  of  these  substances,  the  store  of  body  fat  is 
unduly  drawn  upon  to  supply  the  requisite  energy.  "Under  conditions 
which  involve  a  large  destruction  of  fat  in  the  body,  as  in  starvation, 
fevers,  and  especially  diabetes,  B.  oxybutyric  acid  together  with 
aceto-acetic  acid  and  acetone  are  excreted  in  the  urine.  These  three 
substances  are  designated  as  the  acetone  bodies  and  their  appearance 
in  the  urine  makes  the  condition  known  as  acetonuria."  (Howell.) 
Why  the  oxidization  of  fats  in  many  of  these  cases  does  not  go  on  to 
completion  is  explained  by  the  fact  that  without  sugar  combustion 
fat  never  burns  to  C02  and  H20.  But  why  the  deprivation  of  sugar 
leads  to  incomplete  oxidization  of  fats  is  not  understood. 

Acidosis  in  Diabetics. — In  diabetes  there  is  a  perverted  condition 
of  metabolism  which  is  represented  chiefly  by  a  failure  to  store  surplus 
sugar,  i.  e.,  to  form  glycogen,  and  an  inability  on  the  part  of  the 
tissues  to  use  sugar  for  energy.  As  a  result,  in  severe  cases,  the  store 
of  body  fat  is  unduly  drawn  upon  to  supply  requisite  energy.  This 
is  intensified  if  the  demand  for  carbohydrates  is  increased  by  exercise, 
operation,  fright,  etc.  If  this  condition  of  abnormal  katabolism  pro- 
gresses to  a  marked  degree  acidosis  results. 

When  the  usual  symptoms  of  diabetes,  e.  g.,  thirst,  increased  appetite 
and  glycosuria  are  replaced  by  anorexia,  nausea,  vomiting  and  gastric 
tenderness,  or  if  the  patient  becomes  unusually  drowsy,  his  intellect 
dull  and  his  mind  and  body  readily  fatigued,  an  acidosis  should  be 
suspected.  If  examination  of  the  urine  shows  the  presence  of  acetone 
bodies  the  diagnosis  is  verified. 

Acidosis  is  not  likely  to  develop  in  mild  cases  of  diabetes,  that  is, 
in  cases  in  which  glucose  disappears  from  the  urine  on  a  carbohydrate 
free  diet;  on  the  other  hand,  acidosis  is  to  be  feared  in  cases  in  which 
glucose  does  not  disappear  on  such  a  diet. 

A  diabetic  patient  who  has  been  secreting  small  amounts  of  acetone 
is  prone  to  develop  symptoms  of  acidosis  under  conditions  which  over- 
tax his  powers;  such  as,  strong  mental  or  bodily  exertion,  infec- 
tious diseases,  acute  alcoholic  intoxication  and  chloroform  or  ether 
narcosis. 

Diabetics  are  poor  surgical  risks  not  only  because  of  the  danger 
of  acidosis,  but  also  on  account  of  the  relatively  poor  reparative 
power  of  their  tissues  and  the  lack  of  resistance  of  their  tissues  to 
infection. 

In  connection  with  the  surgical  risk  in  patients  presenting  diabetes, 
it  is  important  to  emphasize  that  ammonia  estimation  in  a  twenty- 
four-hour  specimen  of  urine  should  always  be  made  before  operation. 
"  Since  the  acid  in  excess  of  amounts  that  are  neutralized  by  the  fixed 
bases  combines  with  ammonia  and  is  excreted  as  an  ammonia  salt, 
it  is  evident  that  increased  ammonia  in  the  urine  is  a  rough  estimate 


118  SHOCK  AND  ALLIED  CONDITIONS 

of  the  degree  of  acidosis."1  Two  grams  of  ammonia  always  indicates 
an  extremely  bad  operative  risk;  approximately  one  gram  may  be 
supported  but,  if  possible,  such  a  patient  should  receive  preliminary 

treatment.  If  the  ammonia  is  in  excess  of  21,  grams  it  cannot  be 
expected  that  the  patient  will  survive  an  operation.  Patients  pre- 
senting ammonia  to  the  amount  of  H  grams  should  be  treated  with 
repeated  alkaline  infusions  as  a  prophylactic  measure.  It  is  important 
that  this  treatment  should  not  be  deferred  until  the  development 
of  diabetic  coma. 

Acidosis  in  Norirdiabetics. — Individuals  who  are  apparently  normal 
may  show  a  trace  of  acetone  in  the  blood  and  the  urine.  The  aceto- 
nemia and  acetonuria  are  increased  by  fasting  or  a  limitation  of  the 
carbohydrate  intake,  by  reason  of  the  incomplete  katabolism  of  the 
body  fats  which  are  drawn  upon.  The  by-products  of  this  katabolism 
are  the  acetone  bodies  and  if  these  are  produced  and  accumulate  in 
the  body  in  sufficient  amount,  the  symptoms  of  acidosis  may  develop. 
An  anesthetic  administered  to  an  individual  presenting  acetonuria  or 
symptoms  of  acidosis  frequently  aggravates  the  condition.  To  a 
severe  degree  of  acidosis  have  been  ascribed  certain  severe  symptoms 
which  in  some  cases  terminate  in  the  patient's  death.  (Brew'er;  Brack- 
ett,  Stone  and  Low;  Favill.)  However,  it  has  not  been  proved  that 
acidosis  is  the  exclusive  causative  factor. 

Symptoms  of  Acidosis  in  Non-diabetics. — The  patients  are  usually 
young;  they  present,  besides  acetonuria,  some  of  the  following  symp- 
toms; headache,  vertigo,  tachycardia,  dyspnea,  nervousness  and  a 
peculiar  sweetish  odor  to  the  breath.  They  are  apt  to  take  an  anes- 
thetic badly  and  to  remain  stupid  or  unconscious  for  an  unusually 
long  time  after  the  anesthetic  is  discontinued. 

Postanesthetic  Acidosis.- — It  has  been  noted  not  infrequently  that 
after  the  administration  of  an  anesthetic  a  patient  has  developed  acid- 
osis. In  a  large  majority  of  cases  chloroform  has  been  the  anesthetic 
used  and  the  condition  has  sometimes  been  termed  "Delayed  Chloro- 
form Poisoning;"2  yet  the  condition  has  been  noted  in  rare  cases  after 
ether. 

This  type  of  poisoning  has  occurred  most  frequently  in  children, 
in  whom  fright,  change  of  environment  and  food  favor  a  disturbance 
of  metabolism.  A  long  operation,  the  repetition  of  the  induction  of 
anesthesia  within  a  few  days,  high  fevers,  acute  diseases  of  the  stomach 
and  intestines,  inanition,  stricture  of  the  esophagus  and  diseases  of 
the  kidneys  and  liver  predispose  to  the  occurrence  of  acetonuria. 

In  nearly  all  of  the  fatal  cases  of  postanesthetic  acidosis  in  non- 
diabetics  the  pathological  findings  have  been  reported  as  an  acute 
degeneration  of  the  liver  similar  to  that  found  in  acute  yellow  atrophy 
or  phosphorus  poisoning. 

1  N.  B.  Foster,  Diabetes  Mellitus. 

2  Howland  and  Richards  believe  that  delayed  chloroform  poisoning  is  not  due  to  acid 
intoxication. 


ACIDOSIS  119 

Symptoms. — After  operation,  in  mild  eases  the  patient  has  a  distaste 
for  food,  is  nauseated  and  on  about  the  fourth  or  fifth  day  vomits. 
These  symptoms  clear  up  under  appropriate  treatment. 

In  the  more  severe  cases,  vomiting  becomes  persistent  and  there 
is  a  sweetish  odor  to  the  breath,  the  patient  looks  very  sick,  his 
face  has  a  grayish  pallor,  the  skin  is  cold  and  clammy,  the  pulse 
rapid  and  weak;  the  patient  may  sink  into  a  condition  of  collapse 
and  death  may  ensue.  At  times  death  is  preceded  by  restlessness, 
delirium,  convulsions,  dyspnea,  Cheyne-Stokes'  respiration,  cyanosis 
and  coma.     Jaundice  is  present  in  some  cases. 

Treatment. — Prophylaxis. — In  this  connection  Van  Xoorden's  dic- 
tum is  of  interest;  that  in  the  normal  individual  "acetonuria  can  in 
every  case  be  prevented  by  the  administration  of  abundance  of 
carbohydrate  food." 

Before  an  anesthetic  is  administered,  the  urine  should  be  examined 
for  acetone;  if  acetone  is  found,  the  urine  should  be  tested  for  diacetic 
acid.  If  one  or  both  are  present  operation  should  be  delayed  until  the 
acidosis  is  overcome.  For  this  purpose  carbohydrates  and  alkaline 
fluids  should  be  given  freely.  Sodium  bicarbonate,  gr.  xv  every  four 
hours,  should  be  given  by  mouth  until  the  urine  is  distinctly  alkaline. 
Carbohydrates  should  be  administered  by  mouth,  and  glucose  in  5 
per  cent,  solution  may  be  given  by  rectum. 

Before  the  operation  a  small  dose  of  morphine  should  be  given  to 
reduce  the  amount  of  anesthetic  required:  chloroform  should  not  be 
employed,  except  on  rare  occasions  and  then  only  for  a  short  period. 
An  enema  containing  5  j  of  olive  oil  and  g  j  of  glucose,  to  be  retained, 
may  be  given  just  before  or  after  the  operation. 

Active  Treatment. — If  acidosis  develops  after  an  operation  alkalies 
and  carbohydrates  should  be  administered  freely.  wSodium  bicarbonate, 
5ss  every  hour  by  mouth  or,  if  the  vomiting  is  severe,  a  Murphy  drip 
of  5  per  cent,  solution  of  sodium  bicarbonate  should  be  given.  Hypo- 
dermoclysis  is  not  to  be  recommended  because  abscess  formation  some- 
times results.  Foster  recommends  intravenous  infusion  of  5  per  cent, 
sodium  bicarbonate,  or  4  per  cent,  sodium  carbonate,  200  c.c.  every 
two  hours  until  a  liter  has  been  given,  using  the  salvarsan  apparatus. 
Glucose  may  be  given  by  mouth  or  rectum ;  by  mouth,  as  a  powder  or 
in  solution;  by  rectum,  as  a  5  per  cent,  solution  to  be  retained,  or  as 
a  continuous  drip.  In  severe  cases,  not  diabetic,  Foster  recommends 
glucose  in  four  to  five  per  cent,  solution  of  distilled  water,  giving  100  c.c. 
at  intervals  of  two  to  four  hours  until  the  symptoms  are  relieved  or  until 
1000  c.c.  have  been  given.  For  severe  vomiting  tincture  of  iodine, 
Tfl.v  in  half  an  ounce  of  water  in  repeated  doses,  has  been  recommended. 
In  grave  cases  exhibiting  marked  jaundice  with  progressive  toxemia 
there  is  no  treatment  which  offers  any  hope ;  the  condition  is  practi- 
cally the  same  as  in  other  forms  of  acute  yellow  atrophy  of  the  liver. 


120  SHOCK  AND  ALLIED  CONDITIONS 

CARDIAC   WEAKNESS. 

The  condition  of  the  heart  may  be  an  important  factor  in  the  success 
or  failure  of  an  operation.  Not  infrequently  operative  deaths  have 
been  the  direct  result  of  pathological  changes  in  the  valves  or  the 
myocardium. 

Valvular  disease,  if  uncompensated,  is  a  contra-indication  to 
surgical  procedures,  especially  under  general  anesthesia.  Failure  of 
compensation  is  usually  readily  recognized  by  such  symptoms  as 
rapid  and  irregular  heart  action,  dyspnea,  cough,  dropsy  and  signs  of 
passive  congestion  or  edema  of  the  lungs.  Valvular  disease,  if  fully 
compensated,  and  if  not  accompanied  by  circulatory  disturbances  under 
conditions  of  moderate  physical  exertion,  should  not  deter  the  surgeon 
from  administering  an  anesthetic  and  undertaking  important  opera- 
tions. 

The  condition  of  the  heart  muscle  is  of  the  greatest  importance 
from  a  surgical  standpoint.  Changes  in  the  myocardium  are  due  to 
a  number  of  causes,  among  which  may  be  mentioned  acute  and  chronic 
infections,  exhausting  diseases,  nephritis,  alcoholism,  general  arterio- 
sclerosis, obstruction  of  the  coronary  arteries  and  obesity.  These  may 
result  in  fibrosis,  fatty  infiltration  and  degenerative  changes,  especially 
fatty  degeneration. 

Symptoms. — Chronic  myocarditis  may  not  give  rise  to  any  symptoms 
or  physical  signs,  and  the  existence  of  cardiac  weakness  may  not  be  sus- 
pected until  the  sudden  development  of  serious  symptoms  during  an 
operation.  On  the  other  hand,  the  pulse  may  be  feeble,  abnormally 
slow  or  fast,  with  attacks  of  arhythmia  and  dyspnea  on  exertion;  the 
first  sound  may  be  weakened  and  occasionally  a  murmur  is  present. 
Arhythmia  is  said  to  be  more  serious  than  regular  tachycardia.  The 
walls  of  the  peripheral  arteries  are  frequently  thickened,  and  hyperten- 
sion often  accompanies  a  chronic  myocarditis;  it  may  be  possible  to 
recognize  physical  signs  of  general  cardiac  hypertrophy.  In  a  person 
past  the  prime  of  life,  especially  in  men  who  have  led  active  business 
lives,  these  symptoms  and  signs  should  be  sought  before  operation  is 
advised.  Their  recognition  may  modify  the  decision  as  to  the  advisa- 
bility nature  of  an  operation. 

In  cases  with  myocardial  changes  death  may  occur  without  warning 
on  the  operating  table  or  from  slight  exertion  during  recovery  from  the 
anesthetic.  In  other  instances  the  patient  may  become  gradually 
cyanosed  during  the  operation,  with  increased  rapidity  and  decreased 
force  of  the  pulse  beat,  which  does  not  respond  to  stimulation.  Death 
may  occur  within  a  few  hours. 

In  patients  predisposed  to  this  condition  the  occurrence  of  cyanosis, 
not  due  to  spasm  of  the  glottis  or  bronchorrhea,  especially  if  asso- 
ciated with  rapid,  irregular  and  weak  pulse,  demands  the  immediate 
cessation  of  the  anesthetic  and  the  inauguration  of  stimulating 
measures. 


UREMIA  121 

A  type  of  cardiac  weakness  which  has  received  considerable  atten- 
tion recently  is  the  "myoma  heart,"1  that  is,  cardiac  weakness  in 
women  having  fibromyomata  of  the  uterus.  It  is  supposed  to  be  caused 
by  toxins. 

The  symptoms  of  this  condition  may  be  shortness  of  breath,  palpita- 
tion, precordial  distress,  irregularity  of  pulse  and  frequent  headaches. 
Fleck  reported  12  deaths  in  325  cases,  directly  or  indirectly  due  to 
cardiac  changes;  3  without  operation  (1  from  embolism,  2  from  myo- 
cardial changes  (brown  atrophy) ) ;  9  died  at  the  operation  or  shortly 
afterward. 

UREMIA. 

The  effect  of  a  severe  trauma,  sepsis,  or  surgical  operation  requir- 
ing general  anesthesia  in  individuals  who  have  kidney  disease,  is 
often  to  provoke  an  acute  exacerbation  and  to  produce  a  fatal 
toxemia.  While  in  the  majority  of  instances  the  anesthetic  is  the 
chief  cause  of  the  disturbance,  the  condition  of  sepsis,  the  shock 
of  trauma  or  operation,  and  loss  of  blood,  may  act  as  contributing 
causes  by  lowering  the  resistance  of  the  patient.  While  any  disease 
of  the  kidneys  which  impairs  their  function  may  give  rise  to  uremia 
after  operation,  the  condition  known  as  chronic  Bright's  disease, 
associated  with  both  parenchymatous  and  interstitial  changes  in  the 
organs,  and  the  cases  of  septic  pyelonephritis  which  have  passed  the 
acute  stage  and  in  which  the  disease  often  exists  as  a  latent  disorder 
for  a  long  period  of  time  without  symptoms,  are  the  conditions  most 
to  be  feared.  As  the  embarrassment  of  the  renal  function  in  these 
cases  is  due  largely  to  an  acute  hyperemia  of  the  organ  produced 
by  the  elimination  of  large  quantities  of  the  anesthetic,  and  other 
toxic  substances  generated  by  the  anesthetic  or  the  disease  for  which 
the  operation  is  undertaken,  the  length  of  operation  and  amount  of 
the  anesthetic  agent  used,  as  well  as  the  method  of  its  administration, 
will  be  found  to  be  important  factors.  Long  exposure  on  the  operating 
table  with  insufficient  or  wet  covering  will  favor  renal  congestion  by 
lowering  the  surface  temperature. 

Symptoms. — The  symptoms  of  toxemia  from  renal  insufficiency  are 
too  well  known  to  need  description;  apathy,  somnolence,  dry  foul 
tongue,  high-tension  pulse,  diminished  secretion  of  urine,  and  gen- 
eral appearance  of  illness,  with  increase  in  the  temperature  and 
other  evidences  of  wound  infection,  should  always  excite  suspicion  of 
renal  trouble,  and  measures  should  at  once  be  undertaken  to  promote 
elimination  and  prevent  further  poisoning.  In  these  cases  examina- 
tion of  the  urine  will  show  it  to  be  scanty,  albuminous,  and  often 
bloody;  casts  are  present  and  the  output  of  solids  is  diminished.  In 
the  severe  cases  there  may  be  absolute  suppression  of  urine  with  a 

1  Doane,  Surg.,  Gynec.  and  Obst.,  January,  1912;  Barrows,  Amer.  Jour.  Surg.,  1912, 
xxvi,  161;    Fleck,  Arch.  f.  Gynak.,  1904,  lxxi,  258. 


122  SHOCK  AND  ALLIED  CONDITIONS 

rapidly  developing  coma,  Cheyne-Stokes  respiration,  convulsions,  and 
death. 

Treatment. — Early  treatment  is  often  of  great  value  in  this  con- 
dition, and  lives  are  frequently  saved  by  judicious  management. 
The  administration  of  large  quantities  of  water  by  the  mouth,  saline 
rectal  irrigations,  intravenous  infusions,  hot-air  baths,  cathartics,  digi- 
talis, nitroglycerin,  dry  cups  over  the  loins,  milk  diet,  and  general 
stimulating  measures  are  to  be  employed. 

HEAT-PROSTRATION. 

Gibson  has  called  attention  to  the  fact  that  individuals  under 
general  anesthesia  are  apparently  very  susceptible  to  the  prostrating 
efl'ects  of  heat.  Patients  undergoing  surgical  operations  during  hot 
weather,  especially  if  preceded  by  a  long  period  of  fasting,  not  infre- 
quently exhibit  symptoms  of  profound  weakness  accompanied  by  a 
rapid,  feeble  pulse,  exceedingly  high  temperature,  and  mental  con- 
fusion or  delirium.  The  symptoms  sometimes  appear  immediately 
after  the  operation,  always  within  a  few  hours,  and  long  before  septic 
influences  could  produce  such  effects.  In  a  case  recently  under  the 
observation  of  the  writer  the  removal  of  a  pharyngeal  growth  was  fol- 
lowed in  a  few  hours  by  a  rise  of  temperature  to  106°  F.,  with  a 
pulse  of  1()0.  Under  appropriate  treatment  the  pulse  and  tempera- 
ture gradually  fell  to  normal  without  evidences  of  sepsis.  In  another 
and  fatal  instance,  an  easy  and  short  laparotomy  was  immediately 
followed  by  a  rise  in  temperature  which  in  twelve  hours  reached 
109.4°  F. 

Treatment. — The  treatment  of  these  cases  should  be  by  cold  water 
and  stimulation.  Placing  the  patient  on  a  rubber  sheet  and  sprinkling 
with  cold  water  from  an  ordinary  garden  sprinkling  pot,  every  two  or 
three  hours,  will  often  produce  a  marked  improvement  in  the 
symptoms. 

Ehrenfried  calls  attention  to  the  importance  of  prophylaxis.  He 
states  that  when  the  operating  room  has  a  temperature  of  90°  F.  or 
over,  a  large  ice-cap  should  be  held  by  the  anesthetist  against  the 
patient's  occipital  region. 

HEMORRHAGE. 

Hemorrhage,  or  the  escape  of  blood  from  the  vessels,  occurs  as  a 
result  of  trauma,  surgical  operation,  or  disease.  Traumatic  hemorrhage 
may  be  external,  if  the  loss  of  blood  occurs  from  a  wound  of  the  skin 
or  soft  parts;  internal,  or  concealed,  if  the  bleeding  occurs  into  one  of 
the  cavities  of  the  body;  or  subcutaneous,  if  it  takes  place  into  the 
soft  tissues  beneath  an  unbroken  skin. 

A  hemorrhage  is  said  to  be  primary  when  it  occurs  at  the  time  of 
the  trauma;  intermediate  or  recurrent,  when  it  occurs  after  a  few  hours 
— twelve  to  forty-eight;  secondary,  when  it  occurs  after  a  few  days — 


HEMORRHAGE  123 

from  two  to  the  complete  healing  of  the  wound.  Bleeding  may  occur 
from  the  arteries,  veins,  or  capillaries,  or  from  all  combined.  Arterial 
hemorrhage  is  generally  recognized  by  the  bright  scarlet  color  of  the 
blood,  and  by  the  fact  that  it  occurs  in  jets  synchronous  with  the  pulse; 
venous  hemorrhage,  by  the  steady  flow  of  dark-colored  blood  which  is 
easily  controlled  by  pressure;  capillary,  by  the  general  oozing  of  blood 
from  a  large  area  of  divided  tissue.  Extensive  subcutaneous  hemor- 
rhages, if  arterial,  give  rise  to  large  pulsating  tumors — false  aneurism*; 
if  venous,  to  large  collections  of  blood — hematomata — which  do  not 
pulsate  (unless  situated  immediately  over  an  artery),  and  in  which  the 
sensation  of  fluctuation  can  be  obtained.  Ecchymoses,  or  "black  and 
blue  marks,"  represent  subcutaneous  hemorrhages  too  small  in  amount 
to  form  distinct  tumors. 

Hemorrhage  from  disease  may  occur  in  the  brain — cerebral  apoplexy 
— where  it  is  generally  the  result  of  endarteritis;  from  the  nose — epis- 
taxis — where  it  results  from  congestion  or  ulceration  of  the  mucous 
membrane;  from  the  lung — hemoptysis — which  is  often  the  earliest 
symptom  of  tuberculosis;  from  the  stomach — hematemesis — caused  by 
new  growth,  ulcer,  passive  congestion,  or  intense  inflammation;  from 
the  bowels — melena;  from  tumors,  acute  or  chronic  ulceration,  or 
congestion;  from  the  urinary  organs — hematuria — from  new  growth  or 
disease  of  the  kidney,  bladder,  prostate,  or  urethra. 

Alarming  hemorrhages  occasionally  occur  from  slight  and  insig- 
nificant traumata,  due  to  an  hereditary  condition  known  as  hemo- 
philia. Little  is  known  regarding  the  etiology  of  this  condition  other 
than  the  fact  that  this  tendency  to  hemorrhage  is  transmitted  from 
one  generation  to  another.  Such  individuals  are  called  bleeders,  and 
they  should  not  be  subjected  to  surgical  operation  except  under  con- 
ditions of  extreme  emergency. 

Symptoms. — A  moderate  loss  of  blood  in  a  vigorous,  healthy  indi- 
vidual produces  no  symptoms  other  than  a  feeling  of  slight  weakness. 
If  the  amount  lost  is  greater,  there  is  a  feeling  of  giddiness,  dyspnea 
on  exertion,  mental  confusion,  and  a  disposition  to  faint.  In  severe 
cases  there  may  be  in  addition  thirst,  air-hunger,  partial  blindness, 
ringing  in  the  ears,  and  suspended  consciousness.  Accompanying  these 
symptoms  there  are  pallor,  coldness  of  the  extremities,  a  moist,  clammy 
skin,  rapid,  sighing  respiration,  and  restlessness.  The  pulse  is  rapid, 
feeble,  thready,  irregular,  and  compressible;  the  temperature  is  sub- 
normal; there  is  great  physical  weakness;  nausea  and  vomiting  may 
occur;  the  pupils  are  dilated,  the  eyes  often  fixed,  and  the  counte- 
nance expressionless.  In  continued  hemorrhage  these  symptoms  are 
all  exaggerated,  consciousness  is  lost,  tremor  or  convulsions  may  be 
present,  the  pulse  becomes  imperceptible,  the  heart  fluttering,  and 
death  speedily  occurs.  Da  Costa  states  that  death  may  be  expected 
if  one-half  the  volume  of  blood  is  lost.  It  often  occurs  with  much 
smaller  hemorrhage  if  the  loss  is  rapid  or  accompanied  by  shock  from 
other  causes. 


124 


SHOCK  AND  ALLIED  CONDITIONS 


Treatment. — Nature's  method  of  arresting  hemorrhage  is  by  the 
formation  of  a  clot  in  or  about  the  wound  of  the  vessel.  This  forms 
first  around  the  opening,  then  extends  into  the  lumen  of  the  vessel, 
and  if  undisturbed  causes  its  permanent  closure,  ("lotting  occurs 
early  in  wounds  of  the  smaller  vessels,  especially  the  veins,  which 
collapse  more  readily  than  the  arteries,  and  prevents  a  serious  loss  of 
blood.  In  wounds  of  the  larger  vessels,  however,  the  force  of  the  blood- 
current  prevents  the  formation  of  a  clot  until  the  vascular  tension 
is  greatly  lowered,  often  after  the  patient  lias  fainted.  The  lessened 
force  of  the  blood  current,  which  results  partly  from  the  diminished 
volume  of  blood  in  the  vessels  and  partly  from  vasomotor  paresis  from 
cerebral  anemia,  together  with  a  condition  of  greater  coagulability  of 
the  blood  apparently  present  under  these  circumstances,  finally  results 
in  the  formation  of  coagula  in  the  mouths  of  the  vessels  and  arrests  the 
hemorrhage  before  death  occurs.    In  wounds  of  the  larger  trunks  the 


Fig.  38. — Rubber  tubing  applied  to  arrest  hemorrhage. 


patient   is   quickly   exsanguinated  and   death  results  before  nature*s 
processes  have  begun. 

In  the  treatment  of  hemorrhage  from  any  vessel  of  considerable 
size  only  one  method  should  be  employed  by  the  surgeon,  and  that 
is,  to  expose,  isolate,  and  securely  ligate  the  bleeding  artery  or  vein. 
No  other  method  gives  the  same  degree  of  safety  to  the  patient  or  the 
same  feeling  of  security  to  the  surgeon.  Many  circumstances,  however, 
may  be  present  which  will  prevent  the  carrying  out  of  this  plan,  and 
under  these  conditions  other  methods  must  be  employed.  The  appli- 
cation of  a  tourniquet  above  the  bleeding  point  is  perhaps  the  method 
most  generally  employed  for  the  temporary  arrest  of  severe  hemorrhage 
from  an  injured  limb.  In  the  absence  of  a  regularly  constructed  tour- 
niquet, the  best  material  for  this  purpose  is  a  medium-sized  piece  of 
rubber  tubing  (Fig.  38),  large  enough  to  avoid  cutting  the  skin  and 
sufficiently  elastic  to  exert  considerable  pressure  when  snugly  applied. 
This  should  be  made  to  encircle  the  limb,  should  be  well  drawn  out,  and 
tied  or  securely  held  by  forceps,  care  being  taken  to  avoid  pressure 


HEMORRHAGE 


125 


on  the  nerve  trunks.  In  the  absence  of  rubber  tubing  any  strong 
material  may  be  used,  as  a  flannel  or  muslin  bandage,  a  strip  of  folded 
cotton  or  linen  cloth,  or  even  a  skein  of  worsted.  These  should  be 
tied  tightly  about  the  limb  and  additional  pressure  exerted  by  twisting 
with  a  stick  I  Fig.  39).  Digital  pressure  at  the  bleeding  point  or  over 
the  artery  supplying  the  part  will  often  be  serviceable  in  temporarily 
arresting  a  hemorrhage  until  other  and  more  permanent  means  can 
be  employed.  Mechanical  compression  by  means  of  sponge  or  gauze 
packing  applied  to  the  bleeding  point  and  firmly  held  by  a  bandage  is 
serviceable,  especially  in  venous  bleeding  or  capillary  oozing.  Hyper- 
flexion  at  certain  joints,  as  the  knee  and  elbow,  with  or  without  a  pad 
of  gauze  or  cotton  at  the  angle  of  flexion,  will  often  serve  to  compress 
the  artery  and  arrest  hemorrhage.  The  flexion  should  be  maintained 
by  bandage,  and  can  be  borne  only  for  a  short 
time.  Elevation  of  the  limb  causes  at  once  a 
diminution  in  the  amount  of  blood  lost,  and 
in  connection  with  other  temporary  measures 
will  often  be  successful.  The  application  of 
hot  water  or  ice  to  a  bleeding  part  is  often  em- 
ployed with  success  in  venous  and  capillary 
oozing.  Certain  chemical  agents,  called  styp- 
tics, have  the  power  of  producing  firm  clots, 
and  are  occasionally  employed,  especially  in 
the  throat  and  nasal  cavities.  Of  these  the 
persulphate  of  iron  in  powder  or  solution 
(Monsel's  solution  or  salt)  has  been  most 
frequently  employed.  Tannin,  alum,  anti- 
pyrin,  cocaine,  and  adrenalin  are  also  exten- 
sively employed,  the  two  last  chiefly  on 
mucous  membranes.  Strong  hydrogen  perox- 
ide has  been  found  by  the  writer  to  be  useful 
in  controlling  capillary  oozing  in  wounds, 
and  also  in  mucous  membrane  hemorrhages, 
and  has  the  advantage  of  being  as  well  a 
powerful  antiseptic  agent.  Acetone  is  ex- 
tremely useful  to  control  bleeding  from  the  very  friable  tissue  of 
ulcerating  metastatic  carcinoma  such  as  is  found  secondary  to  carci- 
noma of  the  breast;  it  may  be  applied  to  small  areas  by  inverting  a 
test-tube  containing  the  fluid  over  the  site  to  be  treated,  allowing  the 
acetone  to  be  in  contact  with  the  bleeding  area  for  a  few  minutes,  or 
gauze  may  be  saturated  with  acetone,  covered  with  rubber  tissue,  to 
prevent  rapid  evaporation,  and  applied  to  the  involved  urea  with 
firm  pressure.  The  actual  cautery  will  occasionally  be  found  of 
value  in  arresting  hemorrhage,  expecially  from  the  cut  surface  of 
bone,  or  the  oozing  from  divided  inflammatory  tissues. 

Of  the  methods  applicable  directly  to  the  bleeding  vessel,  ligature, 
torsion,  acupressure,  and  suture  may  be  employed. 


Fig.  39. — Spanish  windlass. 


126 


SHOCK   AND  ALLIED  CONDITIONS 


Ligature. — The  wound  should  be  held  apart  by  retractors,  and 
sufficiently  enlarged  to  obtain  a  good  view  of  the  bleeding  point;  the 
vessel  should  be  separated  from  the  surrounding  tissues  and  clamped. 
If  an  artery  has  been  completely  divided,  both  ends  should  be  found, 
clamped,  and  ligated.  If  it  has  sustained  a  lateral  wound,  it  should  be 
clamped  above  and  below  the  wound,  divided,  and  each  end  securely 
ligated.  If  a  vein  is  found  to  be  the  source  of  the  hemorrhage,  the 
bleeding  end  should  be  tied.  In  small  lateral  wounds  of  large  and 
important  venous  trunks  the  wounded  edges  should  be  grasped  by  a 
clamp  and  a  lateral  ligature  applied  (Fig.  40).  In  friable  inflamed 
tissues,  in  sloughs,  in  the  dura  mater,  and  often  in  disease  of  the  vessel 
walls,  the  application  of  a  ligature  by  means  of  a  curved  needle  passed 
around  the  vessel  through  the  surrounding  tissues  is  to  be  recom- 
mended. When  possible,  absorbable  ligature  material  should  be 
employed.     For  small   vessels  and   in  wounds  which  are  expected 


Fig.  40. — Lateral  ligature. 


to  heal  primarily  ordinary  sterile  catgut  is  to  be  preferred.  For  the 
large  arteries,  and  often  in  wounds  which  are  left  open  or  are  expected 
to  suppurate,  chromicized  catgut  or  silk  may  be  employed. 

Torsion. — Twisting  the  divided  end  of  an  artery  will  often  arrest 
bleeding  by  rupture  and  inversion  of  its  inner  coats.  It  has  the  advan- 
tage of  leaving  no  foreign  material  in  the  wound,  which  in  plastic 
operations  may  occasionally  prevent  accurate  coaptation.  Small 
vessels  may  be  successfully  closed  by  simply  making  two  or  three 
revolutions  of  the  clamp.  In  large  vessels  the  surrounding  tissue 
should  be  removed  and  the  exposed  artery  held  gently  by  a  forceps 
while  the  end  is  clamped  and  twisted. 

Acupressure. — An  old  method  seldom  used  at  present.  It  consists 
in  introducing  a  needle  or  hare-lip  pin  through  the  skin  under  the 
vessel  and  applying  pressure  by  means  of  a  figure-of-eight  ligature  or 
by  twisting  the  pin  over  the  vessel  and  forcing  it  again  into  the  tissues. 


HEMORRHAGE  127 

Suture  of  a  Wounded  IY.s-.sv7. — "Wounds  in  large  venous  trunks,  too 
large  to  be  closed  by  lateral  ligature,  may  often  be  sutured  with  fine 
silk.  The  sutures  should  be  introduced  with  a  fine  round  needle,  and 
should  include  all  the  coats  of  the  vessel.  In  arterial  wounds  the 
problem  is  far  more  difficult,  owing  to  the  fact  that  the  blood-pressure 
is  higher,  and  the  fact  that  the  sutures  are  apt  to  tear  out  by  the 
alternating  dilatation  and  contraction  of  the  vessel  wall.  In  the 
majority  of  instances,  however,  if  the  arterial  wall  is  in  a  normal  con- 
dition, carefully  introduced  fine  silk  sutures  will  be  successful  in  closing 
a  longitudinal  wound.  In  more  extensive  wounds,  division  of  the  vessel 
and  end-to-end  anastomosis  by  the  method  of  Carrel  should  be  em- 
ployed. In  cases  of  abnormally  high  arterial  tension,  and  in  cases  of 
thickened  and  calcareous  arterial  walls,  closure  of  small  wounds  may 
be  accomplished  by  the  use  of  an  aseptic  rubber  adhesive  plaster, 
which  is  wrapped  around  the  vessel  and  allowed  to  remain  imbedded 
in  the  tissues.  The  writer  demonstrated  the  feasibility  of  this  plan 
by  a  series  of  animal  experiments  which  were  reported  to  the  New 
York  Surgical  Society  in  1904.1 

In  the  treatment  of  recurrent  and  secondary  hemorrhages  pressure 
may  be  tried  if  no  important  vessels  are  involved  and  if  the  bleeding 
is  moderate.  In  all  other  cases  the  wound  should  be  opened  and  the 
bleeding  vessel  secured.  This  in  recurrent  or  intermediary  hemorrhage 
is  generally  easy;  but  in  secondary  hemorrhage,  where  the  bleeding  is 
usually  due  to  necrosis  of  the  vessel  wall  from  infection  of  the  surround- 
ing tissues,  considerable  difficulty  may  be  experienced,  and  ligature  of 
the  main  arterial  trunk  above  the  wound  may  be  indicated. 

The  treatment  necessary  to  overcome  the  systemic  effect  of  a 
severe  hemorrhage  consists  in  absolute  rest  in  bed  with  the  head  low- 
ered and  the  trunk  and  extremities  elevated.  The  heart  should  be 
stimulated  by  whiskey,  strychnine,  digitalis,  and  atropine;  and 
the  volume  of  blood  increased  by  direct  transfusion  or  by  a  large 
intravenous  infusion  of  normal  salt  solution.  Heat  should  be  applied 
to  the  surface  of  the  body  by  means  of  warm  blankets  and  hot-water 
bottles;  fluid  food  should  be  taken  by  the  stomach  or  given  by  the 
rectum.  In  severe  cases  with  recurring  syncope  death  can  sometimes 
be  averted  by  applying  elastic  bandages  to  all  four  extremities,  thereby 
forcing  all  available  blood  into  the  vessels  of  the  trunk  and  brain.  The 
after-treatment  should  consist  in  rest,  an  abundance  of  nutritious  food, 
with  iron,  arsenic,  and  large  quantities  of  beef-juice,  bovinene,  or  beef 
peptonoids.  Calcium  chloride  or  lactate  in  full  doses  is  highly  recom- 
mended for  persistent  capillary  hemorrhages;  also  before  operation 
when  a  strong  tendency  to  hemorrhage  is  known  to  exist. 

The  treatment  of  special  hemorrhages  associated  with  visceral  and 
other  traumata  will  be  considered  elsewhere. 

1  Annals  of  Surgery,  December,  1904. 


CHAPTER  VII. 
SURGICAL  TECHNIC. 

ASEPSIS   AND   ANTISEPSIS. 

Before  the  discovery  of  the  relationship  between  micro-organisms 
and  wound  infection,  and  the  general  acceptance  of  the  germ  theory 
of  infectious  diseases,  little  or  no  effort  was  made  by  surgeons  to  employ 
more  than  ordinary  cleanliness  in  their  surgical  work.  The  region  of 
the  wound  rarely  was  washed,  the  surgeon  generally  carried  his  dress- 
ings in  his  pocket,  his  needles  and  sutures  in  his  medicine-case,  and 
washed  his  hands  after  rather  than  before  operation.  Practically  all 
wounds  were  infected,  fully  90  per  cent,  suppurated,  postoperative 
pus  was  supposed  to  be  a  normal  accompaniment  of  repair,  and  the 
death  rate  from  pyemia,  septicemia,  tetanus,  and  erysipelas  after 
severe  traumata  and  surgical  operations  was  very  high.  The  discovery 
in  1867,  by  Sir  Joseph  Lister,  of  the  bacterial  cause  of  wound  infection, 
and  the  demonstration  by  him  of  the  results  obtained  by  his  new 
method  of  wound  treatment,  inaugurated  a  reform  in  surgical  tech- 
nic  which  was  immediately  taken  up  by  surgeons  in  all  parts  of 
the  world.  During  the  past  twenty  years  these  methods  have  been 
considerably  modified  and  improved,  and  have  resulted  in  the  modern 
perfected  aseptic  and  antiseptic  technic  now  almost  universally 
employed  by  surgeons. 

Two  methods  of  wound  treatment  are  in  general  use  at  present,  the 
antiseptic  or  germ-killing  method  and  the  aseptic  or  germ-excluding 
method.  Both  methods  have  for  their  object  the  rendering  of  the 
wound  sterile  or  free  from  pathogenic  micro-organisms.  The  neces- 
sity for  these  methods  depends  upon  the  now  generally  accepted 
fact  that  micro-organisms  are  practically  everywhere  present;  no 
object  can  be  regarded  as  free  from  them  until  it  has  been  subjected 
to  a  process  of  sterilization.  Sterility  is  something  more  than  cleanli- 
ness. A  freshly  laundered  pocket-handkerchief  lying  in  a  dainty 
bureau-drawer  may  be  said  to  be  clean,  but  it  is  not  sterile,  and  would 
not  be  suitable  for  a  wound  dressing  until  it  had  been  subjected  to 
dry  or  moist  heat  at  the  temperature  of  212°  F.  or  above,  for  half  an 
hour  at  least,  or  had  been  soaked  in  some  strong  antiseptic  solution. 
Any  subsequent  contact  with  an  unsterilized  object  would  immediately 
destroy  its  sterility  and  render  it  again  unfit  for  a  wound  dressing. 

The  antiseptic  method  was  first  used  by  Lister,  and  consists  in 
removing  as  far  as  possible  pathogenic  organisms  from  the  wound 


ASEPSIS  AND  ANTISEPSIS  129 

of  the  patient  and  the  hands  of  the  operator  and  his  assistants  by 
vigorous  scrubbing  with  soap  and  water,  and  afterward  killing  the 
remaining  germs  or  those  subsequently  introduced  into  the  wound, 
by  the  generous  employment  of  solutions  of  chemical  disinfecting 
agents,  as  carbolic  acid,  mercuric  chloride,  etc.  The  instruments, 
sponges,  gowns,  towels,  dressings,  etc.,  are  all  to  be  rendered  sterile 
before  being  brought  into  contact  with  the  wound  area. 

This  method,  formerly  universally  employed,  is  now  used  chiefly  in 
infected  cases  and  in  those  in  which  the  more  perfect  aseptic  method 
cannot  be  successfully  carried  out. 

The  aseptic  method  is  the  more  modern,  and  is  a  decided  improve- 
ment over  the  preceding  when  it  can  be  perfectly  carried  out.  It  does 
away  with  the  necessity  of  employing  antiseptic  agents  by  insuring 
absolute  sterility  of  everything  which  may  by  any  possibility  be 
brought  into  contact  with  the  wound.  It  has,  however,  two  weak 
points,  the  skin  of  the  patient  and  the  air  of  the  operating- 
room,  neither  of  which  can  with  certainty  be  rendered  sterile. 
Practically,  however,  these  factors  are  of  little  moment,  as  infec- 
tion rarely  occurs  which  cannot  be  traced  to  other  sources  of  con- 
tamination. 

The  aseptic  method  is  applicable  to  all  cases  in  which  the  wound 
area  is  free  from  infection  at  the  time  of  operation,  when  the  operator 
can  have  the  advantage  of  a  well-equipped  operating-room  and  trained 
assistants.  When  these  cannot  be  had,  or  when  errors  of  technic 
occur,  antiseptic  measures  must  also  be  employed. 

The  methods  of  skin  disinfection,  and  the  preparation  of  the  instru- 
ments, sponges,  dressings,  gowns,  sheets,  towels,  etc.,  are  the  same  in 
both  methods,  and  are  as  follows: 

Preparation  of  the  Patient. — When  possible  a  full  bath  should  be  taken 
the  day  before  the  operation,  followed  by  shaving  the  wound  area 
and  as  much  of  the  surrounding  skin  as  will  be  exposed  on  the  table. 
The  part  should  then  be  scrubbed  with  soap  and  hot  water  for  two 
minutes,  after  which  a  soap  poultice  should  be  applied  for  severa 
hours.  The  morning  of  the  operation  the  parts  should  again  be 
scrubbed  with  soap  and  water  for  from  three  to  five  minutes,  a  sterile 
towel  or  mass  of  fluffed  gauze  being  employed  by  a  nurse  or  assistant 
after  thorough  disinfection  of  the  hands  and  after  having  drawn  on 
a  pair  of  sterile  rubber  gloves.  A  wet  bichloride  dressing  (1  to  5000) 
should  then  be  applied.  This  should  be  removed  on  the  operating- 
table  and  the  part  scrubbed  for  one  minute,  afterward  douched  with 
alcohol,  ether,  bichloride  solution,  and  sterile  water.  Another  good 
method  is  as  follows:  Shave  the  part  to  be  operated  on  the  evening 
before  operation;  wash  with  benzine  to  thoroughly  dry  the  surface, 
paint  with  3.5  per  cent,  tincture  of  iodine;  allow  to  dry  and  apply 
a  dry  sterile  gauze  dressing.  On  the  operating-table  the  gauze  is 
removed  and  a  fresh  coat  of  3.5  per  cent,  tincture  of  iodine  is  applied 
and  allowed  to  dry  thoroughly  and  remain  on  for  three  minutes. 
9 


130  SURGICAL   TECH  NIC 

The  excess  of  iodine  may  then  be  removed  by  alcohol.  For  an  emer- 
gency case  the  part  is  shaved  dry  and  painted  with  7  per  cent,  tincture 
of  iodine.  This  should  be  allowed  to  dry  for  eight  minutes,  then  to 
prevent  its  burning  the  excess  of  iodine  is  removed  by  alcohol.  This 
should  be  done  by  mopping  the  surface,  not  by  rubbing.  The  wound 
area  should  then  be  surrounded  by  a  sterile  sheet  or  sterile  towels 
which  cover  all  parts  of  the  body  and  operating-table  likely  to  be 
touched  by  the  surgeon,  his  assistants,  or  instruments. 

Preparation  of  the  Operator,  His  Assistants,  and  the  Nurses. — All 
should  be  clothed  in  sterile  gowns  or  suits,  the  head  covered  with  a 
cap,  face  and  mouth  protected  by  gauze  or  a  helmet  of  cotton  cloth, 
and  the  sleeves  rolled  up  above  the  elbows.  The  hands  and  arms  should 
be  prepared  by  scrubbing  with  soap  and  frequent  changes  of  hot 
water  for  five  minutes,  a  sterile  nail-brush  being  employed.  Particular 
attention  should  be  given  to  the  region  of  the  nails,  which  should  be 
previously  cleansed  with  a  pointed  orange-wood  stick  or  other  nail- 
cleaner.  After  scrubbing  for  five  minutes  a  paste  may  be  made  in 
the  hand  by  moistening  a  mixture  of  equal  parts  of  chlorinated  lime 
and  washing-soda  with  a  little  hot  water.  When  this  becomes  slightly 
warm  and  free  chlorine  gas  is  given  off,  the  paste  should  be  thoroughly 
rubbed  on  the  hands  and  arms,  and  afterward  completely  removed 
by  bathing  in  sterile  water  and  mercuric  chloride.  Or  after  scrubbing 
as  above  with  soap  and  water,  the  hands  may  be  immersed  in  alcohol 
for  two  minutes.  Freshly  sterilized  rubber  gloves  should  then  be 
drawn  on  the  hands  and  worn  by  all  participating  in  the  operation. 
The  rubber  gloves  may  be  sterilized  by  boiling  or  by  placing  in  live 
steam  for  twenty  minutes  at  10  lbs.  pressure,  and  dried  in  vacuum 
autoclave. 

Preparation  of  the  Instruments,  Silk,  Silkworm  Gut,  Silver  Wire,  etc.— 
These  are  all  rendered  absolutely  sterile  by  boiling  for  five  minutes 
in  a  1  per  cent,  solution  of  sodium  carbonate  (anthrax  and  subtilis 
spores  are  killed  by  boiling  water  in  two  minutes).  The  instruments 
should  afterward  be  transferred  to  sterile  water,  as  the  sodium  solu- 
tion renders  them  too  slippery  to  be  easily  held.  Knives,  scissors,  and 
needles  are  rendered  dull  by  frequent  boiling.  These  may  be  sterilized 
by  immersion  in  pure  carbolic  acid,  afterward  rinsing  in  alcohol  and 
sterile  water. 

Preparation  of  Suture  and  Ligature  Material. — The  materials  used  for 
sutures  and  ligatures  are  silk,  silkworm  gut,  catgut,  chromicized  cat- 
gut, kangaroo  tendon,  horse  hair,  and  silver  wire. 

Silk,  silkworm  gut,  horse  hair,  and  silver  wire  may  be  sterilized  by 
boiling,  or  by  subjecting  them  to  live  steam  of  a  temperature  of  212°  F. 
or  above  for  one  hour.  Catgut  may  be  sterilized  by  the  following  four 
methods: 

1.  Place  the  catgut  in  a  glass  flask  of  ether,  shake  frequently  for 
six  hours,  then  change  to  a  flask  of  absolute  alcohol  and  shake  fre- 
quently for  six  hours,  then  in  a  flask  of  10  per  cent,  solution  of  carbolic 


ASEPSIS  AND  ANTISEPSIS  131 

acid  in  absolute  alcohol  and  shake  at  intervals  for  six  hours  more, 
after  which  store  in  absolute  alcohol  until  used. 

2.  After  treating  with  ether  and  alcohol  as  above,  boil  in  alcohol 
under  pressure  for  thirty  minutes. 

3.  Iodine  catgut  is  prepared  by  Bartlett  in  the  following  manner: 
Cut  strands  of  suitable  size  and  wind  into  small  coils.  Suspend  the 
coils  in  liquid  petrolatum  heated  on  a  sand  bath  to  212°  F.  for  twelve 
hours,  then  raised  to  300°  F.,  after  which  the  coils  are  transferred  to 
a  solution  composed  of  1  part  of  iodine  flakes  to  110  parts  of  Columbian 
spirits. 

4.  Roosevelt  Hospital  method:  Raw  catgut  is  immersed  in  the 
following  solution: 

Hydrarg.  bichloride,  gr.  xv 

Acid  tartaric,  gr.  lxxv 

Ether, 

Columbian  spirits,  aa     Oj. — M. 

No.  1  should  be  allowed  to  remain  in  the  solution  six  hours,  No.  2, 
eight  hours,  No.  3,  twelve  hours,  No.  4,  sixteen  hours,  No.  5,  twenty 
hours;    after  which  the  catgut  is  stored  in  Columbian  spirits. 

Many  other  methods  are  in  use,  including  that  by  cumol  and  forma- 
lin. Where  cumol  is  employed  the  catgut  is  subjected  to  very  high 
heat,  350°;  this  is  the  method  employed  by  most  commercial  houses. 
It  requires  a  special  apparatus  and  considerable  experience  to  properly 
prepare  the  catgut. 

Chromicized  catgut  may  be  prepared  by  soaking  the  catgut  in  a 
solution  of  chromic  acid,  made  by  dissolving  30  grains  of  the  crystals 
in  1  pint  of  a  5  per  cent,  aqueous  solution  of  carbolic  acid,  and  allowing 
it  to  remain  in  the  solution  from  six  to  twenty-four  hours,  after  which 
it  should  be  wound  on  a  frame  and  thoroughly  dried,  and  then  sterilized 
by  any  of  the  above  methods. 

Preparation  of  Gauze  Dressings  and  Sponges,  Cotton  Gowns,  Sheets, 
Towels,  etc. — These  are  best  sterilized  by  live  steam  under  pressure, 
but  they  may  be  sterilized  by  dry  heat.  One  of  the  modern  steam 
autoclaves  (Fig.  41)  should  be  used  if  possible.  By  means  of  this  the 
live  steam  is  introduced  to  the  articles  to  be  sterilized  (1)  after  they 
have  become  heated  so  there  is  no  water  of  condensation  and  (2)  after 
all  air  has  been  removed  from  their  interstices  by  means  of  a  vacuum 
pump.  They  may  be  subjected  to  the  action  of  live  steam  under  high 
pressure  for  any  length  of  time,  but  thirty  minutes  at  20  lbs.  pressure 
is  sufficient  to  kill  all  bacteria  and  their  spores.  It  is  also  possible 
prior  to  the  removal  of  the  sterilized  goods  to  exhaust  the  steam  and 
thoroughly  dry  them.  By  means  of  the  Arnold  sterilizer  (Fig.  42) 
dressings  may  be  subjected  to  the  action  of  live  steam,  but  not  under 
pressure.  This  kills  the  fully  developed  pus-producing  bacteria,  but  not 
the  spores.  A  fairly  satisfactory  improvised  sterilizer  may  easily  be 
made  out  of  an  ordinary  wash-boiler.    Take  two  bricks,  place  them  in 


132 


SURGICAL  TECH  NIC 


the  bottom  of  the  boiler,  pour  in  about  two  quarts  of  water,  and  then 
cover  the  bricks  by  two  or  three  long  strips  of  thin  board  laid  length- 
wise. On  these  place  the  various  bundles  of  sheets,  towels,  gowns, 
bandages,  dressings,  etc.,  to  be  sterilized.  Put  the  cover  on  the  wash- 
boiler  and  place  it  on  the  kitchen  range  for  thirty  minutes,  after  which 
the  materials  will  be  ready  for  use.  When  this  cannot  be  obtained, 
freshly  laundered  sheets,  which  are  practically  free  from  germs,  or 

clean  towels  soaked  in  bichloride 
solution  (1  to  1000),  can  be  used,  and 
the  sponges  and  dressings  can  be 
boiled  for  two  minutes  and  allowed 
to  cool  before  using. 

Marine  sponges  are  rarely  used  in 
aseptic  surgery  on  account  of  the 
difficulty  in  their  sterilization.  They 
should  be  freed  from  sand  and  dust, 
bleached,  and  kept  in  a  1  to  20  solu- 
tion of  carbolic  acid  for  several 
weeks. 

All  instrument-trays,  sponge  basins, 
and  other  glassware  should  be  kept 
scrupulously    clean,    sterilized    in    a 


Fig.  41. — Steam  autoclave. 


Fig.  42. — Arnold  sterilizer. 


large  steam  sterilizer,  or  immersed  in  a  large  tub  of  bichloride  (1  to  1000) 
for  thirty  minutes,  and  afterward  rinsed  in  sterile  water. 

Irrigating  solutions  should  be  made  with  distilled  or  boiled  water. 
Normal  salt  solution  may  be  made  by  dissolving  K)0  grains  of  chemic- 
ally pure  sodium  chloride  in  32  ounces  of  water  and  boiling  for  two 
minutes.  If  it  is  to  be  used  for  intravenous  infusion,  it  should  be 
filtered. 

General  Management  of  an  Operating-room. —While  each  surgeon 
should  arrange  the  duties  of  his  assistants  and  the  general  details  of 


BANDAGING  133 

his  operative  technic  to  suit  his  own  ideas  and  purposes,  a  few 
general  rules  should  he  observed  in  all  well-regulated  operating  plants. 
The  operating  stall'  of  a  large  general  hospital  should  consist,  in 
addition  to  the  operating  surgeon,  of  two  sterile  assistants  and  two 
sterile  nurses.  In  addition  to  these  there  should  be  one  or  two  extra 
attendants,  nurses  or  orderlies,  to  assist  in  moving  the  patient,  to 
regulate  the  position  of  the  operating  table,  handle  the  electric  lights, 
cautery,  irrigating  cans,  etc.,  and  to  assist  the  anesthetist. 

The  first  assistant  should  stand  opposite  the  operator,  sponge  and 
clamp  vessels;  the  second  assistant  should  handle  the  retractors;  the 
chief  operating  nurse  should  have  charge  of  the  instrument-tray,  the 
ligature  and  suture  material;  the  assistant  nurse  should  handle  the 
sponges,  towels,  sheets,  and  pads.  Each  assistant  should  thoroughly 
understand  his  or  her  duties  and  should  follow  the  operator  and  antici- 
pate his  wants.  As  far  as  possible,  talking  should  be  avoided  by  those 
participating  in  the  operation  as  it  has  been  repeatedly  demonstrated 
that  infection  may  occur  by  contamination  of  the  wound  area  by 
minute  quantities  of  mucus  or  saliva  from  the  mouths  of  talking 
operators  or  assistants.  To  avoid  this  possibility  and  also  to  prevent 
any  loose  hairs  or  dandruff  dropping  into  the  wound,  face  masks  and 
hoods  of  gauze  or  cotton  cloth  should  be  worn  by  all  the  assistants  and 
nurses. 

Good  team  work  on  the  part  of  the  operator  and  assistants  is  the 
essential  factor  in  perfect  operating-room  technic.  Loud  talking 
and  angry  criticism  on  the  part  of  an  operator  generally  defeats  his 
object  by  rendering  the  assistants  nervous  and  hasty  in  their  various 
duties,  which,  in  turn,  always  favors  the  occurrence  of  technical  errors. 

The  rough  handling  of  the  tissues,  the  tearing  apart  of  anatomic 
structures,  bruising  the  wound  edges  by  forcible  retraction,  and  the 
inclusion  of  large  masses  of  tissue  in  hemostatic  ligatures  are  to  be 
avoided  as  favoring  infection.  Other  things  being  equal,  the  best 
results  will  be  obtained  by  the  surgeon  who  performs  his  operation 
in  the  shortest  time  and  with  the  minimum  of  exposure  and  trauma 
to  the  tissues. 

BANDAGING. 

Bandages  are  used  in  surgery  chiefly  to  hold  in  place  surgical  dress- 
ings and  splints;  they  are  also  employed  to  exert  pressure  on  certain 
parts  and  thereby  to  relieve  congestion,  to  promote  absorption  of 
extravasated  fluids  or  exudates,  to  prevent  edema,  to  support  weak- 
walled  vessels,  as  well  as  to  give  protection  and  support  to  injured 
limbs  and  joints. 

The  materials  used  for  bandages  are  gauze,  muslin,  crinolin,  rubber, 
flannel,  canton  flannel,  and  fabrics  impregnated  with  plaster  of  Paris, 
starch,  dextrin,  and  other  hardening  substances.  For  holding  dress- 
ings in  place,  the  muslin  or  gauze  bandage  is  commonly  employed;  for 
supporting  varicose  veins,  applying  pressure  to  a  limb  or  joint,  the 


134 


SURGICAL   TECHXIC 


rubber  or  flannel  bandage  is  used;  while  to  insure  fixation  of  a  broken 
limb  or  injured  joint,  the  plaster  of  Paris,  starch,  or  dextrin  bandage 
is  to  be  recommended. 

Roller  Bandages.  -If  the  part  to  be  bandaged  is  of  even  size  through- 
out, as  the  upper  arm  or  trunk,  the  free  end  of  the  bandage  is  laid  upon 
the  part  and  held  in  place  by  the  left  hand,  while  the  roller  is  carried 


Fig.  43. — Ascending  spiral  bandage.     (Wharton.) 

by  the  right  hand  around  the  part  to  be  bandaged  in  such  a  way  that 
the  second  turn  will  hold  the  first  firmly  in  place.  Each  revolution  of 
the  bandage  covers  at  least  one-half  of  the  last  turn.  When  the  upper 
limit  of  the  bandage  is  reached,  the  end  is  pinned  to  the  layer  beneath 
(Fig.  43).  If  the  part  to  be  bandaged  is  conical,  as  the  leg  or  forearm, 
the  spiral  reversed  bandage  is  applied,  in  which  each  turn  is  made 
to  fit  snugly  to  the  limb  by  being  turned  upon  itself,  as  seen  in  Fig. 


Pig.  44. — Method  of  making  reverses.     (Wharton.) 


44;  or  the  figure-of-eight  bandage  is  employed,  in  which  the  lower 
loops  of  bandage  are  snugly  and  evenly  adapted  to  the  limb,  and  as 
the  bandage  a>cends  they  eventually  cover  the  more  loosely  applied 
upper  loops  (Fig.  45).  In  applying  a  bandage  to  the  groin  or  shoulder, 
the  spiea  is  employed,  beginning  on  the  limb  and  making  a  figure-of- 
eight  around  the  limb  and  trunk,  as  seen  in  Fig.  4(3.    In  bandaging 


BANDAGING 


135 


the  thumb  or  one  of  the  fingers  the  free  extremity  is  covered  with  the 
spiral/ reversed ;  and  when  the  base  is  reached  the  spica  is  used,  the 
upper  loop  of  which  encircles  the  digit  and  the  lower  loop  the  hand  and 


Fig.  45. — Figure-of-eight  bandage  of  leg.     (Park.) 

wrist  (Fig.  47).  In  bandaging  the  knee,  the  figure-of-eight  is  used, 
the  first  turn  being  taken  around  the  joint  opposite  the  middle  of  the 
patella,  after  which  the  loops  alternate,  one  being  applied  above  and 


Fig.  46. — Ascending  spica  bandage  of  the 
groin.     (Wharton.) 


Fig.  47. — Spiral   bandage  of  the   finger. 
(Wharton.) 


the  next  below  the  first  turn  (Fig.  48).  In  bandaging  the  head,  one 
or  two  loops  are  made  to  encircle  the  head,  passing  from  the  frontal 
region  just  above  the  eyes  around  the  occipital  protuberance;  a  figure 


130 


SURGICAL   TECH  NIC 


Fig.  48. — Figure-of-eight  bandage  of  the  knee.     (Wharton.) 


Fig.   49. — Transverse  recurrent  bandage       Fig.  50. — Recurrent  bandage  of  the  head, 
of  the  head.     (Wharton.)  (Wharton.) 


Fig.  51. — Recurrent  bandage  of  a  stump.     (Wharton.) 


BANDAGING  137 

of-eight  bandage  is  then  applied  in  a  transverse  direction,  beginning 
just  above  one  ear  and  carrying  the  first  turn  over  the  centre  of  the 
vault  to  the  opposite  ear;  then  a  number  of  turns  are  taken  between 
these  two  points  alternately  in  front  of  and  behind  the  first  until  the 
entire  vault  is  covered.  The  loops  made  by  reversing  the  bandage 
just  above  each  ear  are  firmly  held  until  all  the  transverse  turns  are 
made,  and  finally  secured  by  three  or  four  encircling  turns  around  the 
forehead  and  occiput,  safety-pins  being  finally  introduced  to  hold  all 
in  place  (Fig.  49).  The  folds  covering  the  vault  may  also  be  made 
longitudinally  if  desired  (Fig.  50). 

In  bandaging  an  amputation-stump,  make  one  or  two  circular 
turns  around  the  circumference  of  the  stump,  then  a  number  of  turns 
at  a  right  angle  to  these,  inclosing  the  extremity,  and  holding  these 


Fig.  52. — Modified  Velpeau  dressing.     (Wharton.) 

in  place  by  a  circular  or  reversed  spiral  from  the  extremity  upward 
until  a  joint  or  some  bony  protuberance  is  covered  to  hold  it  in  place 
(Fig.  51). 

The  Modified  Velpeau  Bandage. — To  apply  the  modified  Velpeau 
bandage  for  holding  the  arm  securely  to  the  chest  wall.  Place  the 
hand  on  the  opposite  shoulder;  take  two  or  three  turns  of  a  wide 
roller  bandage  around  the  thorax,  including  the  arm;  then  pass  the 
bandage  from  the  free  axilla  behind  to  the  fixed  shoulder,  passing 
over  this  shoulder  from  behind  forward;  carry  the  bandage  around 
the  point  of  the  elbow  and  then  upward  behind  the  same  shoulder 
over  its  summit  downward  in  front  to  the  free  axilla,  then  circularly 
around  the  chest,  alternating  these  turns  until  the  entire  arm  and  chest 
are  included  (Fig.  52). 

All  of  these  methods  may  be  modified  to  meet  special  indications. 


138 


SURGICAL   TECHN1C 


Fig.  54. — Breast  binder. 


BANDAGING  139 

Triangular  or  Folded  Handkerchief  Bandage. — The  triangular  or 
folded  handkerchief  bandage  is  made  by  folding  a  square  piece  of 
muslin  or  gauze  into  a  triangle.  This  can  be  applied  over  a  bulky 
dressing  of  the  hand  or  amputation-stump  by  placing  the  base  of  the 
triangle  at  right  angles  to  the  limb  and  folding  the  apex  over  its  extrem- 
ity, and  securing  it  by  wrapping  the  two  extremities  of  the  base  snugly 
around  the  limb  and  tying  them.  This  bandage  may  also  be  employed 
on  the  head. 


Fig.  55. — Breast  binder. 

T-bandage. — The  T-bandage  is  used  for  dressings  applied  to  the 
perineum,  the  horizontal  arms  encircling  the  trunk,  the  perpendicular 
arm  passing  between  the  thighs  from  behind  upward  and  fastened  to 
the  front  of  the  body  portion  (Fig.  53). 

Many-tailed  Bandage. — The  many-tailed  bandage  is  useful  for 
almost  any  part  where  dressings  are  frequently  changed.     It  is  par- 


140 


SURGICAL   TECHNIC 


Fig.  56. — Jaw  bandage. 


Fig.  57. — Triangular  sling. 


BANDAGING  141 

ticularly  serviceable  when  a  firm  abdominal  binder  is  required  and  in 
breast  amputations. 

Two-tailed  Jaw  Bandage.— The  two-tailed  jaw  bandage  is  useful 
for  holding  the  lower  jaw  firmly  against  the  upper,  as  in  fractures  of 
the  lower  jaw  or  in  wounds  of  the  chin  (Fig.  56). 

Sling. — The  sling,  to  support  the  forearm  and  arm,  is  made  by 
folding  a  large  piece  of  muslin  into  a  triangle.    Place  the  two  extrem- 


Sling  and  chest  binder. 


ities  of  the  base  line  around  the  neck  and  allow  the  forearm  to  rest  in 
the  loop  (Fig.  57). 

The  Sling  and  Chest  binder.— This  is  a  very  useful  bandage  for 
fixing  the  arm  to  the  chest,  and  is  used  in  fractures  of  the  clavicle  and 
humerus,  injuries  to  the  shoulder  and  elbow.  Place  one  extremity  of 
a  triangular  sling  in  place  around  the  neck,  flex  the  elbow  and  place 
the  forearm  across  the  chest,  then  apply  a  chest  binder  including  the 
upper  arm,  and  fix  with  safety-pins,  after  which  the  other  extremity 


142 


SURGICAL   TECHMC 


of  the  sling  is  folded  around  the  forearm  and  carried  upward  around 
the  neck  and  tied  to  the  one  already  in  place;  fasten  all  these  layers 
together  with  safety-pins  (Figs.  58  and  59). 

Plaster-of-Paris  Bandages. — Plaster-of-Paris  bandages  are  used 
whenever  a  fixed  stiff  dressing  is  required  for  protection  or  to  limit 
mobility.  They  are  made  by  rubbing  plaster  of  Paris  into  the  meshes 
of  a  gauze  or  crinolin  bandage.  The  part  should  first  be  covered 
with  a  layer  of  sheet  wadding,  cotton,  or  lint.  The  plaster  bandages 
are  then  placed  in  cold  water.  When  the  bandage  is  thoroughly 
soaked  it  should  be  grasped  at  each  end  and  gently  squeezed  toward 


Fig.  59. — Sling  and  cheat  hinder. 


the  centre  and  applied  over  the  layer  of  wadding.  Care  should  be 
taken  to  apply  the  layers  evenly,  and  in  general  the  figure-of-eight 
should  be  used  on  a  conical  part  rather  than  the  reversed  spiral,  as 
the  wet  bandage  when  reversed  is  apt  to  roll  itself  into  a  hard  cord, 
which  may  produce  subsequent  discomfort.  Good  plaster  will  set  or 
harden  in  a  few  minutes.  These  dressings  are  removed  by  cutting  or 
sawing  through  the  plaster  down  the  front  or  along  one  side.  In  thick 
casts  this  is  often  difficult,  and  can  be  made  easier  by  moistening  with 
a  strong  solution  of  mercuric  chloride,  dilute  hydrochloric  acid,  or 
hydrogen  peroxide. 


WOUND   Dh'KSSI.XCS 


143 


WOUND   DRESSINGS. 

Clean,  freshly  made  wounds  are  best  dressed  with  sterile  dry  gauze, 
which  is  simply  held  in  place  by  a  bandage.  The  dressing  should  be 
large  enough  to  extend  well  beyond  the 
wound-limits,  and  secured  firmly  enough 
to  prevent  being  displaced  and  exposing 
any  part  of  the  wound.  The  use  of  thin 
silver  foil  next  to  the  wound  or  a  layer  of 
gauze  wet  with  a  1  to  100  solution  of  for- 
malin will  serve  to  prevent  stitch  infection 
from  Staphylococcus  epidermidis  albus. 
If  there  is  reason  to  suppose  that  the 
wound  is  infected,  provision  should  be 
made  for  drainage  by  leaving  the  wound 
partly  open,  and  packing  with  gauze  im- 
pregnated with  sterile  albolene,  by  the  in- 
troduction of  a  rubber  drainage-tube  (Fig. 
60),  or  by  the  use  of  a  thin  strip  of  folded 
sterile  rubber  protective  tissue.  If  the 
wound  is  a  deep  one,  or  in   one   of  the 

body  cavities,  or  if  an  abundant  fluid  discharge  is  expected,  a  double 
rubber  drainage-tube  may  be  employed,  or,  especially  in  the  abdominal 
cavity,the  cigarette  drain  will  be  found  useful.     This  consists  in  a  roll 


Fig.  60. — Rubber  drainage-tube. 


W: 


Fig.  61. — Cigarette  drains. 


144 


SURGICAL   TECH  NIC 


of  gauze  covered  by  thin  rubber  tubing  or  rubber  protective  tissue 
(Fig.  61).  In  making  these  the  gauze  should  not  be  rolled  too  tightly, 
but  loosely  so  that  wound  secretions  may  drain  out  through  it. 

Wet  Dressings. — Infected  or  open  wounds  are  often  treated  by  wet 
dressings.  Several  layers  of  gauze  are  wet  with  some  antiseptic  solu- 
tion and  placed  next  to  the  wound;  this  is  covered  with  oiled  silk  or 
rubber  tissue  to  prevent  too  rapid  evaporation,  and  held  in  place  by 
a  roller  or  many-tailed  bandage.  Wet  dressings  should  be  frequently 
opened  and  more  of  the  solution  added.  Of  the  solutions  most  used, 
mercuric  chloride,  1  to  5000  to  1  to  1000;  aluminium  acetate  (1  part  of 
alum,  25  parts  of  lead  acetate,  and  500  parts  of  water) ;  carbolic  acid, 
1  to  500  to  1  to  100;  Thiersch's  solution,  made  by  dissolving  1  part  of 
boric  acid  and  6  parts  of  salicylic  acid  in  500  parts  of  water;  and  myrrh 
wash,  made  by  adding  1  part  of  tincture  of  myrrh  to  12  parts  of  water. 
The  latter  is  very  useful  in  foul  suppurating  wounds.  Abscess  cavities 
and  long  suppurating  sinuses  should  be  dressed  once  or  twice  daily, 
irrigated  with  some  antiseptic  solution,  as  a  weak  solution  of  tincture 
of  iodine,  and  allowed  to  heal  from  the  bottom.  Such  cavities,  if 
indolent,  should  be  packed  with  gauze  soaked  in  balsam  of  Peru  or 
"red  wash/5  which  is  a  mixture  of  2  parts  of  zinc  sulphate  and  100  parts 
of  tincture  of  lavender  in  500  parts  of  water. 

LIGATURES. 

Wounded  vessels  should  be  clamped  and  ligated.  If  possible,  an 
absorbable  ligature  should  be  used.     Sterile  catgut  is  the  material  to 


Fig.  62.— Reef  or  flat  knot. 


Fig.  63. — Granny  knot. 


Fig.  64. — Surgeon's  knot. 


be  recommended,  the  smaller  sizes  for  small  vessels,  larger  sizes  for 
medium-sized  vessels,  and  medium  or  heavy  chromicized  catgut  for 


METHODS  OF   WOUND  CLOSURE 


145 


the  larger  arteries.  When  sterile  catgut  cannot  he  had,  silk  should  be 
used.  If  neither  can  be  obtained,  ordinary  linen  thread  boiled  for 
ten  minutes  will  answer  the  purpose. 

The  reef  or  square  knot  (Fig.  62),  the  granny  knot  (Fig.  03),  and 
the  surgeon's  knot  (Fig.  64)  are  the  ones  generally  employed.  The 
Ballance  and  Edmunds  knot  is  highly  recommended  in  the  ligature  of 
large  arteries.  Two  strands  of  floss  silk  are  passed  around  the  vessel 
and  the  first  half  of  a  knot  tied  in  each  separately;  then  both  strands 
are  taken  together  and  the  last  half  of  the  knot  tied  as  one. 

METHODS  OF  WOUND  CLOSURE. 

If  the  wound  is  superficial,  aseptic,  and  there  is  no  tension,  the 
divided  edges  of  the  skin  can  be  approximated  and  held  by  a  few  inter- 
rupted sutures  (Fig.  65),  care  being  taken  that  the  edges  of  the  wound 


Fig. 


65. — Interrupted  su- 
ture.    (Park.) 


Fig. 


66. — Continued  su- 
ture.    (Park.) 


Fig.  67.— Chain-stitch 
suture. 


are  in  exact  apposition,  and  not  folded  inward  by  drawing  the  suture 
too  tight.  Tight  suturing  also  favors  marginal  necrosis  and  infection 
by  interfering  with  the  circulation.  Silk,  silkworm  gut,  horse-hair, 
silver  wire,  or  wound  clips  are  to  be  preferred  to  catgut  for  cutaneous 
sutures  for  the  reason  that  catgut  swells,  seals  the  minute  opening 
through  which  it  passes  and  thus  prevents  capillary  drainage.  The 
continuous  suture  is  largely  employed  in  closing  cutaneous  wounds 
(Fig.  66),  also  the  locked  stitch  (Fig.  67)  or  the  mattress  suture  (Fig. 
68).  The  continuous  mattress  suture,  or  Gushing  suture,  is  employed 
by  many  in  intestinal  work  (Fig.  69).  When  considerable  force  is 
needed  to  bring  the  wound  edges  together,  a  few  deep  sutures  intro- 
duced at  some  distance  from  the  wound  margin,  relieve  the  tension  on 
cutaneous  sutures.  Strong  silk  or  silkworm  gut  is  the  best  material 
for  the  purpose. 

In  deep  ivounds  and  amputation-stumps  it  is  often  desirable  to  bring 
the  muscles  and  fascial  layers  together  to  avoid  dead  spaces,  which 
10 


146 


SURGICAL   TECH  NIC 


allow  accumulation  of  blood  and  other  fluids  and  favor  infection. 
This  is  accomplished  best  by  the  introduction  of  a  few  deep  catgut 
sutures.  In  closing  abdominal  wounds  it  is  desirable  to  unite  the  differ- 
ent structures  separately,  in  order  to  prevent  a  subsequent  hernia; 
the  peritoneum  should  be  drawn  together  with  a  continuous  suture 
of  catgut,  the  muscular  and  aponeurotic  layers  with  chromicized  cat- 


Fig.  68. — Mattress  suture,  interrupted. 


Fig.  69. — Cushing  suture. 


gut,  and  the  skin  with  silk  or  silkworm  gut.  Many  surgeons  employ 
the  throughrand-through  suture  of  silkworm  gut  or  silver  wire,  including 
all  layers.  In  the  upper  zone  of  the  abdomen  this  method  may  be 
employed,  as  hernias  rarely  occur  in  this  region.  It  is  to  be  advised 
also  whenever  the  condition  of  the  patient  demands  a  speedy  termina- 
tion of  the  operation,  as  it  requires  much  less  time  than  a  layer  suture. 
The  subcuticular  suture  has  been  extensively  employed  of  late  to 
avoid  stitch  infection  and  to  render  the  scar-line  less  noticeable.  It 
consists  in  the  use  of  fine  silver  wire  or  silkworm  gut  with  a  full- 


Fig.  70. — Subcuticular  suture.    (Wharton.) 

curved  Hagadorn  needle.  The  needle  pierces  the  skin  just  beyond  one 
extremity  of  the  wound  and  emerges  just  within  the  cut  below  the  cutis. 
From  this  point  the  needle  is  passed  through  the  subcuticular  tissues 
first  on  one  side  and  then  on  the  other  until  the  opposite  extremity  is 
reached,  when  the  needle  again  pierces  the  healthy  skin  just  beyond  the 
wound  angle  (Fig.  70).    When  the  suture  is  drawn  tight  the  two  edges 


CATHETERIZATION 


147 


of  the  wound  are  approximated.  Experience  has  shown,  however, 
that  these  scars  eventually  become  as  wide  as  the  others,  and  also  that 
stitch  infection  can  practi- 
cally always  be  prevented 
by  the  use  of  silver  foil  or 
formalin  gauze  over  the  cu- 
taneous wound.  The  use  of 
metal  skin  clips  is  a  rapid 
and  convenient  method  of 
skin  closure  (Fig.  71). 

Cutaneous  approximation 
without  sutures  by  means  of 
strips  of  sterilized  zinc  oxide 

adhesive    plaster,    suggested  Fig.  71.— Metal  skin  clips  and  forceps. 

by  Lilienthal,  is  occasionally 

employed.  The  advantages  are  that  ample  drainage  space  is  provided, 
the  skin  is  not  pierced,  strangulation  of  the  marginal  tissue  is  avoided, 
and  the  chances  of  infection  greatly  reduced. 


CATHETERIZATION. 

Catheterization,  or  the  introduction  of  urethral  instruments,  in  the 
female  is  generally  easy.  If  a  soft-rubber  catheter  is  employed,  the 
tip  is  well  lubricated  with  sterilized  vaselin,  or  lubrichondrine,  and 
introduced  within  the  external  meatus,  after  which  the  catheter  is 
easily  passed  into  the  bladder.  If  a  silver  or  glass  instrument  is 
used,  it  should  be  introduced  with  the  curved  tip  pointing  upward. 
In  catheterizing  the  female,  the  instrument  should  be  introduced 
under  the  direct  vision.  The  nurse  should  stand  on  the  patient's  right. 
The  labia  should  be  separated  by  the  thumb  and  index  finger  of  the 
left  hand,  and  the  catheter  introduced  directly  into  the  meatus  without 
coming  in  contact  with  any  other  part.  In  the  male,  catheterization  is 
more  difficult  owing  to  the  length  of  the  urethra,  its  subpubic  curve, 
and  the  fact  that  the  curved  portion  of  the  canal  is  fixed  by  strong 
ligamentous  structures.  The  subpubic  curve  in  the  adult  male  urethra 
corresponds  to  an  arc  of  a  circle  three  and  one-quarter  inches  in 
diameter;  an  solid  urethral  instruments,  therefore,  should  have  a 
curve  corresponding  with  this.  As  in  the  female,  soft -rubber  and  gum- 
elastic  catheters  or  bougies  are  easily  introduced  into  the  normal  male 
urethra  and  bladder  by  simple  pressure,  the  penis  being  held  at  a 
right  angle  to  the  body.  In  introducing  a  solid  silver  catheter  (Fig.  72) 
or  sound,  the  surgeon  should  stand  on  the  patient's  left,  the  penis  should 
be  grasped  by  the  forefinger  and  thumb  of  the  left  hand,  and  drawn 
upward  on  the  abdomen;  the  instrument,  well  lubricated,  should  be 
held  in  the  right  hand,  the  shaft  being  parallel  with  Poupart's  ligament. 
As  the  sound  glides  into  the  canal  the  shaft  should  gradually  be  carried 
toward  the  median  line  and  elevated,  and  when  the  point  of  the  sound 


148 


SURGICAL   TECH  NIC 


reaches  the  prostatic  portion,  the  shaft  should  be  exactly  in  the  median 
line  of  the  body  and  at  a  right  angle  with  it.  Firm  pressure  should 
then  be  made  by  the  right  hand  over  the  root  of  the  penis,  and  with 
the  left,  the  handle  should  be  gently  depressed  between  the  thighs.  This 
allows  the  beak  to  follow  the  natural  curve  of  the  urethra  and  to  pass 
into  the  bladder.  If  the  calibre  of  the  urethra  is  narrowed  or  deviated 
by  stricture,  periurethral  exudate,  or  enlargement  of  the  prostate,  the 
flexible  gum-elastic  olivary,  coude  or  long  prostatic  catheter  should  be 


Fig.  72.— Metallic 
catheter. 


Fig.  73.— Prostatic 

catheter. 


Fig.   74. — Flexible 
catheters. 


Fig.  75. — Mercier's 
coude  catheter. 


used  (Figs.  73-75).  All  urethral  instruments  should  be  sterilized  before 
introduction,  and  the  region  of  the  meatus  disinfected  by  careful 
wiping  with  a  pledget  of  cotton  wet  with  a  1  to  1000  solution  of  mercuric 
chloride,  (ilass,  metal,  and  soft-rubber  catheters  should  be  sterilized 
by  boiling;  gum-elastic  or  silk  catheters  by  immersion  in  a  solution 
of  bichloride  of  mercury  or  by  formalin  vapor.  If  the  urethral  mucous 
membrane  is  infected,  it  should  be  irrigated  with  bichloride  solution 
(1  to  10,000)  or  potassium  permanganate  (1  to  4000).  In  all  catheteriza- 
tions, the  use  of  sterilized  rubber  gloves  is  to  be  recommended. 


DIRECT  TRANSFUSION  OF  HU)OD  149 


DIRECT    TRANSFUSION    OF    BLOOD. 

The  direct  transfusion  of  blood  from  one  individual  to  another  is 
indicated  in  cases  of  severe  hemorrhage,  grave  secondary  anemia, 
severe  toxemia  from  sepsis,  gas  poisoning  or  acid  intoxication,  hemo- 
philia, congenital  melena,  chronic  icterus,  and  other  conditions  asso- 
ciated with  lessened  coagulability  of  the  blood.  It  is  also  indicated 
to  improve  the  physical  condition  of  a  debilitated  patient  about  to 
undergo  a  surgical  operation.  It  may  also  be  of  value  to  increase 
the  normal  resistance  of  an  individual  in  certain  cases  of  sarcoma 
or  other  malignant  processes,  or  to  render  him  immune  to  certain 
infectious  diseases. 

While  the  advantages  of  direct  transfusion  of  blood  have  been 
recognized  for  centuries,  and  various  more  or  less  ingenious  instruments 
have  been  devised  to  accomplish  this  end,  the  operation  had  been  prac- 
tically abandoned  by  surgeons  for  the  reason  that  it  rarely  succeeded, 
and  in  not  a  few  instances  disastrous  results  followed  their  attempts. 

The  chief  reason  for  failure  was  that  in  the  older  methods  an  attempt 
was  made  to  pass  the  blood  of  the  donor  through  a  rubber,  glass,  or 
metal  tube  to  the  veins  of  the  recipient.  This  almost  invariably 
resulted  in  clotting,  which  quickly  obstructed  the  flow. 

The  demonstration  by  Carrel  that  clotting  could  be  eliminated  by 
end-to-end  suture  of  vessels  in  such  manner  that  intima  was  brought 
into  direct  contact  with  intima,  paved  the  way  for  a  more  rational 
technic. 

Certain  preliminary  precautions  should  be  taken  whenever  possi- 
ble in  order  to  prevent  possible  disastrous  accidents.     Certain  tests 
should  be    made  on  the  blood  of   the   donor, 
c.  g.,  a  Wassermann,  and  between  the  blood  of 
the  donor  and  the  recipient,  e.  g.,  the  agglutina- 
tion   and    hemolysis    tests.      In    the    case    of       *v~ 
brothers   and   sisters   or  parents  and   children 
these  may  be  safely  omitted,  but  in  cases  where     Fic  „6 
no  such  relationship  exists  they  should,  where       sion  cannula.    (X2.) 
possible,  be  carried  out. 

Crile  has  devised  a  simple  cannula  (Fig.  70),  having  a  slightly  conical 
hollow  point  with  two  grooves  on  the  outer  surface.  A  short  handle 
projects  from  one  side  of  the  cannula,  by  which  it  is  held. 

The  technic  of  the  operation  is  as  follows: 

The  recipient  and  donor  are  placed  on  two  tables  and  their  arms 
prepared  in  the  usual  manner.  Under  local  anesthesia  the  radial 
artery  of  the  donor  is  exposed  for  about  two  inches  and  ligated  at  its 
distal  extremity.  A  temporary  clamp  is  next  placed  on  its  proximal 
end  and  the  artery  divided  near  the  ligature.  The  redundant  layer  of 
adventitia  is  drawn  downward  and  cut  off,  and  the  vessel  threaded 
through  the  lumen  in  the  cannula.  The  lumen  of  the  vessel  is  then 
grasped  by  three  equidistant  mosquito  forceps  and  drawn  backward 


150 


SURGICAL   TECH  NIC 


over  the  distal  end  of  the  cannula,  forming  an  inverted  cuff  with  intirna 
outward.  This  is  held  in  place  by  a  ligature  of  fine  silk  placed  over 
the  second  groove.  The  vein  of  the  donor  is  prepared  in  the  same  man- 
ner, its  lumen  expanded  by  three  small  clamps,  and  drawn  over  the 
inverted  arterial  cuff  on  the  cannula.  The  two  are  secured  in  place  by 
a  second  ligature  placed  over  the  first  groove,  which  securely  holds 
the  two  vessels  in  contact.  The  temporary  clamps  are  next  removed 
and  the  blood  allowed  to  flow  into  the  vein  of  the  recipient.  The  flow 
at  first  is  often  slow,  owing  to  the  contraction  of  the  artery  from 
exposure.  The  application  of  wet  compresses  at  a  temperature  of  from 
108°  to  112°  F.  will  generally  bring  about  relaxation  of  the  arterial 
walls,  and  a  vigorous  flow  of  blood  follows,  which  causes  marked  pulsa- 
tions in  the  vein.  Elsburg  has  also  devised  a  cannula  somewhat  similar 
to  that  of  Crile.  It  has  a  lumen  adjustable  by  means  of  a  screw. 
This  on  the  whole  is  an  improvement  on  Crile's  cannula. 


The  above  technic,  while  not  particularly  difficult  to  one  who  has 
had  an  opportunity  of  rehearsing  the  operation  either  upon  an  animal 
or  the  cadaver,  is  often  attended  by  certain  embarrassments,  especially 
in  young  children. 

Recently  Kimpton  has  devised  a  cannula  and  tube  which  he  coats 
with  paraffin  or  Vincent's  mixture.  (Stearin,  1  part;  paraffin,  2 
parts;  vaselin,  2  parts.)  This  tube  consists  of  a  flask  containing  150 
to  250  c.c.  which  has  a  special  neck  (Figs.  77  and  78).  He  exposes  a 
vein  in  donor  and  recipient,  fills  the  tube  from  the  donor  and  then 
rapidly  injects  under  low  pressure  the  blood  into  the  exposed  vein  of 
the  recipient. 


INTRAVENOUS  INFUSION  OF  NORMAL  SALT  SOLUTION      15] 

Linderman  found  that  if  the  blood  was  transmitted  rapidly,  within 
a  minute  or  two,  that  it  could  be  abstracted  from  the  donor's  vein  by 
means  of  a  glass  syringe  and  injected  into  the  veins  of  the  recipient, 
and  did  not  clot  or  cause  any  untoward  results.  He  devised  special 
cannula;  to  fit  veins  of  various  sizes  and  employs  two  dozen  Kecord 
20  c.c.  syringes,  rapidly  changing  and  rinsing  them  as  they  are  used. 


Fig.  78 

Hooker  and  Satterlee  have  devised  a  method  by  which  they  collect 
the  blood  in  50  c.c.  glass  flasks  either  coated  with  paraffin  or  a  weak 
solution  of  hirudin  to  prevent  clotting;  and  by  an  ingenious  cannula 
designed  to  prevent  the  contamination  of  the  blood  with  tissue  juices, 
they  transmit  it  rapidly  and  safely.  They  find  that  with  such  flasks 
several  minutes  may  safely  elapse  before  coagulation  occurs. 

The  latest  improvement  in  the  technic  of  blood  transfusion  is  that 
suggested  by  Lewisohn.  He  found  that  the  addition  of  0.02  per  cent, 
of  sodium  citrate  to  human  blood  prevents  coagulation  for  an  indefi- 
nite period.  His  plan  is  to  draw  the  blood  from  the  donor  by  means 
of  a  simple  cannula,  mix  it  with  the  sodium  citrate,  and  inject  into 
an  exposed  vein  of  the  recipient. 


Fig.  79. — Funnel  and  tube  for  intravenous  injection. 

INTRAVENOUS  INFUSION  OF  NORMAL  SALT  SOLUTION. 

Intravenous  infusion  of  normal  salt  solution  has  advantages  over 
all  other  means  of  rapidly  increasing  the  circulating  medium.  It 
is  accomplished  by  means  of  an  irrigating  jar  or  funnel,  a  rubber 
tube,  and  metal  cannula  (Fig.  79).     Any  superficial  vein  of  sufficient 


152  SURGICAL   TECHNIC 

size  to  receive  the  cannula  will  answer.  Usually  the  median  cephalic 
or  basilic  vein  is  chosen.  This  is  exposed  by  a  short  incision,  cleared, 
and  ligated.  Above  the  point  of  ligature  an  incision  is  made  into 
the  vessel,  the  cannula  introduced  and  held  by  a  second  ligature. 
From  1  to  5  pints  of  normal  sterile  salt  solution  at  a  temperature  of 
from  110°  to  118°  F.  may  be  slowly  introduced  according  to  the 
necessities  of  the  case.  Care  should  be  taken  that  the  tube  and  cannula 
are  filled  with  the  solution  before  the  cannula  is  introduced,  to  avoid 
entrance  of  air.  In  an  emergency  a  satisfactory  infusion  apparatus 
may  be  made  from  an  ordinary  tin  or  glass  funnel,  a  piece  of  rubber 
tubing,  and  a  glass  eye-dropper.  Normal  salt  solution  can  be  made 
by  adding  130  grains  of  chemically  pure  sodium  chloride  to  1  quart 
of  sterile  water.  The  addition  of  adrenalin  chloride  to  the  solution 
is  often  a  valuable  aid  in  the  treatment  of  shock,  aiding  in  the  contrac- 
tion of  the  splanchnic  vessels  and  the  re-establishment  of  vasomotor 
control. 

HYPODERMOCLYSIS. 

Large  amounts  of  fluid  may  be  added  to  the  circulation  by  intro- 
ducing salt  solution  into  the  subcutaneous  connective  tissue.  This 
is  easily  accomplished  by  an  irrigator,  tube,  and  large  aspirating 
needle.  After  sterilization  of  the  apparatus  and  skin  of  the  patient 
the  needle  is  introduced  beneath  the  skin  of  the  abdomen,  thorax, 
thigh,  buttock,  or  in  females  beneath  the  mammary  gland,  and  from 
1  to  2  pints  of  normal  salt  solution  allowed  to  infiltrate  the  tissues. 
This  is  rapidly  absorbed,  and  the  result  though  slower  is  often  satis- 
factory. Oftentimes,  especially  in  marasmic  infants,  a  larger  number  of 
caloric  units  may  be  introduced  in  this  manner  by  adding  glucose  to 
the  solution. 

The  same  result  often  may  be  accomplished  by  prolonged  irrigation 
of  the  rectum  and  colon  by  means  of  the  Kemp  tube. 


CHAPTER   VIII. 
ANESTHESIA. 

The  term  anesthesia  signifies  a  condition  of  insensibility  to  pain. 
An  anesthetic  is  any  agent  which  induces  this  condition.  Anesthetics 
are  divided  into  general  anesthetics  and  local  anesthetics;  the  former 
when  properly  administered  produce  insensibility  to  pain  over  the 
entire  body,  accompanied  by  loss  of  consciousness;  the  latter  produce 
insensibility  over  a  limited  region  only,  not  accompanied  by  uncon- 
sciousness. General  anesthesia  is  induced  by  various  chemicals 
introduced  into  the  blood,  either  in  vapor  form,  by  way  of  the  respira- 
tory tract,  by  way  of  the  colonic  mucous  membrane,  or  in  liquid 
form  directly  into  a  bloodvessel.  The  general  anesthetics  in  common 
use  are  ether,  chloroform,  and  nitrous  oxide.  Local  anesthesia  may 
be  induced  by  the  introduction  of  certain  drugs  subcutaneously  into 
the  spinal  canal  or  into  a  limited  distribution  of  bloodvessels.  The 
local  anesthetics  most  frequently  used  are  novocaine  and  cocaine, 
although  eucaine,  tropacocaine  and  stovaine  may  be  employed. 

Previous  to  the  discovery  of  ether,  nitrous  oxide  and  chloroform, 
the  only  means  which  surgeons  possessed  to  mitigate  the  sufferings 
of  patients  was  the  local  application  of  cold  and  the  administration 
of  opium  and  alcohol.  The  sufferings  experienced  by  those  who 
were  obliged  to  undergo  surgical  operations  limited  the  employment 
of  the  art  of  surgery  to  cases  of  dire  necessity,  and  led  surgeons  in 
their  operative  procedures  to  sacrifice  everything  to  speed.  The 
adaptation,  for  purposes  of  surgical  anesthesia,  of  ether  in  1842  by 
Long  of  Georgia,  and  independently  of  him  in  1846  by  Morton  of 
Boston;  of  nitrous  oxide  in  1844  by  Wells  of  Hartford;  of  chloroform 
in  1847  by  Simpson  of  Edinburgh,  led  to  a  complete  revolution  in 
surgical  procedure.  When  it  was  appreciated  that  by  the  use  of  these 
agents  complete  insensibility  to  pain  could  be  safely  produced  and 
maintained  during  a  protracted  surgical  operation,  many  distressing 
conditions  formerly  untreated  were  brought  to  the  surgeon  for  relief, 
and  as  surgeons  gradually  became  more  deliberate  in  their  work,  a 
higher  perfection  in  technic  resulted. 

General  Anesthesia. — General  anesthesia  is  employed  chiefly  to 
render  surgical  operations  painless,  to  diminish  suffering  during 
parturition,  to  produce  muscular  relaxation  for  the  reduction  of 
fractures,  dislocations  and  occasionally  hernias,  and  for  the  purpose  of 
thorough  physical,  especially  pelvic,  examination.  Occasionally  it  is 
employed  to  give  relief  in  painful  surgical  disorders  such  as  the  passage 
of  a  renal  calculus  or  gall  stone,  or  in  cases  of  intense  neuralgia. 


154  ANESTHESIA 

General  anesthesia  is  contra-indicated  in  cases  of  uncompensated 
valvular  disease  of  the  heart,  in  myocarditis,  in  advanced  arterio- 
sclerosis, in  the  newborn  and  in  the  very  old,  and  in  conditions  of 
very  severe  shock. 

It  is  to  be  distinctly  understood  that  no  one  method  of  anesthesia 
or  any  one  anesthetic  is  indicated  in  all  surgical  cases.  The  choice 
should  be  determined  by  the  conditions  in  each  individual  case.  The 
wise  surgeon  recognizes  the  advantages  of  the  several  anesthetics, 
and  decides  which  anesthetic  is  best  adapted  to  meet  the  needs  of  the 
individual  patient.  Much  harm  is  done  by  the  routine,  thoughtless 
use  of  one  anesthetic  for  all  cases.  Thus,  in  one  patient  ether  may 
light  up  a  quiescent  pulmonary  tuberculosis,  in  another  patient 
chloroform  may  cause  an  acute  exacerbation  of  a  chronic  nephritis, 
in  still  another  nitrous  oxide  may  cause  a  cerebral  hemorrhage  where 
marked  arteriosclerosis  with  high  blood-pressure  is  present. 

Nitrous  Oxide. — Priestley  discovered  the  gas  in  1772.  Sir  Humphrey 
Davy  appreciated  its  anesthetic  properties,  for  in  1800  he  had  a  wisdom 
tooth  extracted  while  under  its  influence.  He  then  made  the  remark- 
able prediction,  "Since  nitrous  oxide  seems  capable  of  destroying 
physical  pain  it  may  be  used  in  surgical  operations  where  there  is 
no  great  effusion  of  blood."  Strangely  enough  his  prophecy  was  not 
fulfilled  until  Horace  Wells  in  1844  began  to  use  it  in  his  dental  prac- 
tice. Ether  and  chloroform  superceded  it,  however,  in  surgical  work 
and  it  is  only  within  the  past  decade  that  it  has  come  to  be  perfected 
and  adopted  as  a  general  anesthetic,  not  alone,  but  in  combination  with 
oxygen.  Since  1900  the  greatest  advances  in  the  field  of  anesthesia 
have  been  made  in  the  administration  of  nitrous  oxide  and  oxygen, 
and  of  nitrous  oxide,  oxygen  and  ether.  This  combination  is  recog- 
nized as  the  best  form  of  anesthesia,  considered  from  every  standpoint, 
available  at  the  present  time.  Credit  for  perfecting  the  necessary 
apparatus  and  the  technic  of  administering  it  is  due  to  such  men  as 
Hewitt,  Teter,  Gwathmey,  Connell  and  Boothby. 

The  indications  for  nitrous  oxide-oxygen  anesthesia  are:  presence 
cf  complicating  pulmonary  or  renal  disease,  sepsis,  diabetes,  cachexia, 
shock.  The  contra-indications  are  the  extremes  of  youth  and  old 
age,  uncompensated  valvular  lesions,  advanced  arteriosclerosis,  with 
high  blood-pressure,  and  the  presence  of  obstruction  to  the  air 
passages,  such  as  enlarged  tonsils,  adenoids,  pharyngeal  or  laryngeal 
growths. 

The  advantages  of  this  anesthesia  when  properly  given  far  outweigh 
the  disadvantages.  The  advantages  are  the  non-irritating,  odorless 
gas,  the  absence  of  excitement  during  its  induction,  the  non-toxicity 
both  during  and  after  anesthesia,  the  absence  of  distressing  after- 
effects such  as  severe  nausea  and  vomiting,  stupor,  headache, 
thirst;  finally,  the  absence  of  postoperative  pulmonary  and  renal 
complications. 

The  disadvantages  are  its  greater  cost  and  the  more  expensive  and 


NITROUS  OXIDE  155 

complicated  apparatus  needed  in  its  administration;  also  the  great 
difficulty  in  securing  deep  anesthesia  and  muscular  relaxation. 

As  administered  today  by  any  one  of  several  apparatuses,  certain 
principles  are  essential.  Nitrous  oxide  should  never  be  used  without 
oxygen  except  for  very  short  operations.  There  should  never  be 
any  obstruction  to  the  air  passages.     Cyanosis  should  constantly  be 


Fig.  80 

avoided  except  in  the  early  stages  of  induction.  There  should  be  a 
regular  and  visibly  controlled  flow  of  both  nitrous  oxide  and  oxygen, 
at  whatever  rate  desired,  at  a  uniformly  low  pressure,  never  over  a 
few  ounces,  into  a  rebreathing  bag  which  should  be  connected  with 
the  face  piece  by  a  wide,  but  short,  connecting  tube.  The  mouth 
piece  should  fit  accurately  to  the  face  and  should  be  air  tight.  There 
should  be  an  efficient  and  easily  controlled  method  of  adding  ether 


15fi  ANESTHESIA 

vapor  to  the  nitrous  oxide  mixture  when  necessary.  The  gases  should 
be  heated  to  body  temperature  at  the  point  of  delivery  to  the  patient. 

The  apparatus  recently  devised  by  Luke  combines  all  these  essential 
features  and  is  by  far  the  most  compact  and  efficient  of  the  many 
apparatuses  now  in  use.     (Fig.  NO.) 

It  is  advisable  in  the  majority  of  cases,  except  in  children,  to  precede 
the  administration  of  this  form  of  anesthesia  with  a  moderate  dose 
of  morphine  and  atropine;  this  places  the  patient  in  a  quiet,  neutral 
state  of  mind  and  provides  for  the  relief  of  pain  when  the  patient 
regains  consciousness  immediately  after  the  anesthesia  is  stopped — 
the  usual  dose  being  morphine  -g-  grain,  atropine  ttg  grain,  hypoder- 
mically,  one-half  hour  before  the  beginning  of  the  anesthesia.  Better 
muscular  relaxation  is  secured  if  the  area  of  incision  is  locally  anes- 
thetized with  novocaine  in  \  to  \  per  cent,  solution.  Co-operation 
on  the  part  of  the  surgeon  in  advising  the  anesthetist  when  a  deeper 
narcosis  is  desired  at  the  time  of  incising  the  peritoneum  or  other 
sensitive  tissues,  assures  a  smoother  anesthesia. 

The  correct  procedure  is  as  follows :  The  apparatus  being  previously 
tested  and  ready,  and  the  patient  having  been  given  instructions  to 
breathe  normally,  and  having  been  quietly  reassured,  the  face  piece 
is  applied  comfortably;  air  only  is  given  at  first,  then  the  air  vent  is 
closed  and  the  nitrous  oxide  is  turned  on.  As  soon  as  the  patient 
begins  to  have  deep  respirations  and  shows  beginning  cyanosis  the 
oxygen  is  turned  on  in  small  amount,  and  as  soon  as  muscular  relaxation 
is  obtained  the  face  piece  is  firmly  secured  to  the  head  and  sufficient 
oxygen  is  added  to  insure  a  pink  color  without  reducing  the  complete 
anesthesia.  The  average  ratio  of  nitrous  oxide  to  oxygen  during  the 
first  hour  of  anesthesia  is  six  liters  of  the  former  to  one  liter  of  the 
latter;  the  proportions  of  the  gases  more  nearly  approach  each  other 
as  the  operation  is  prolonged.  The  symptoms  of  overdosage  of 
nitrous  oxide  are:  cyanosis,  or  when  abundant  oxygen  is  being  used 
with  it,  a  death-like  pallor,  stertorous  breathing,  the  onset  of  excessive 
secretion  of  mucus,  and  shallow  respirations.  These  symptoms,  to- 
gether with  any  respiratory  obstruction,  are  the  danger  signals,  and 
should  be  immediately  treated. 

Addition  of  ether  vapor  is  indicated  whenever  a  mixture  of  nitrous 
oxide  and  oxygen,  with  a  proportion  of  the  latter  sufficient  to  keep 
the  patient's  color  pink,  has  not  produced  a  sufficient  muscular 
relaxation  to  meet  the  demands  of  the  surgeon.  A  few  moments  of 
addition  of  ether  vapor  until  this  relaxation  is  secured  is  usually 
sufficient;  the  remainder  of  the  operation  can  then  be  carried  out  with 
a  return  to  the  nitrous  oxide-oxygen  mixture. 

Ether. — Ether  was  first  discovered  in  the  sixteenth  century.  It 
was  first  used  medicinally  in  1795  in  treating  asthma.  In  1818 
Faraday  observed  that  "when  the  vapor  of  ether  mixed  with  common 
air  is  inhaled  it  produces  effects  very  similar  to  those  occasioned  by 
nitrous    oxide."     Crawford    W.    Long    of    Athens,  Georgia,  having 


ETHER  157 

observed  the  anesthesia  produced  during  "ether  frolics,"  a  prevalent 
amusement,  first  used  ether  as  an  anesthetic  for  a  surgical  operation 
in  1842.  Pie  did  not  publish  his  observations  until  Morton  had, 
quite  independently,  demonstrated  ether  anesthesia  in  1846  in  the 
amphitheatre  of  the  Massachusetts  General  Hospital  in  Boston. 

Stages  of  Ether  Anesthesia. — Properly  administered,  especially 
with  the  modern  improved  methods  of  nitrous  oxide-ether  sequence, 
the  stages  of  ether  anesthesia  are  seldom  seen,  for  the  patient  passes 
smoothly  into  surgical  anesthesia.  When  given  alone,  however,  and 
in  a  certain  number  of  patients  no  matter  what  the  method  used,  four 
stages  may  be  noted. 

First  Stage. — The  stage  of  confusion,  or  light  anesthesia,  is  char- 
acterized by  a  sense  of  giddiness,  mental  confusion,  deepened  and 
irregular  respirations,  increased  blood-pressure,  pulse  full  and  bounding, 
flushed  skin,  increased  salivation,  slight  sense  of  choking.  If  the 
vapor  is  given  in  greater  concentration  the  glottis  closes  and  the 
patient  struggles  to  rid  himself  of  the  cone. 

Second  stage,  or  stage  of  excitement,  is  marked  by  a  loss  of  conscious- 
ness accompanied  by  laughter,  crying  or  unintelligible  talking.  As 
anesthesia  deepens  there  occur  tonic  spasms  of  the  muscles,  especially 
of  the  larynx  and  the  jaw.  Pupils  are  dilated,  but  react  to  light. 
Cyanosis  may  be  present.  Blood-pressure  is  high.  Pulse  is  slow  and 
bounding.  The  patient  may  choke  and  vomit,  or  have  a  violent 
fit  of  coughing.  There  may  develop  a  tremor  of  all  the  muscles. 
This  is  the  stage  that  is  avoided  by  careful  induction  of  the  anesthesia, 
especially  with  the  nitrous  oxide-ether  sequence. 

Third  Stage,  or  Stage  of  Surgical  Anesthesia. — When  this  stage 
is  reached,  and  not  until  then,  the  patient  is  ready  for  the  operative 
procedure.  It  is  characterized  by  muscular  relaxation;  regular,  deep 
respirations;  normal  or  slightly  flushed  color  of  the  skin;  pupils  normal 
in  size  and  reaction;  absence  of  vomiting,  coughing,  and  phonation; 
pulse  full,  regular,  80-100  in  rate. 

Fourth  stage,  stage  of  overdose  or  poisoning,  is  characterized  by 
shallow  respirations;  cyanosis,  or  dusky  pallor;  feeble,  irregular 
pulse  of  low  pressure;  dilated  pupils  which  do  not  react  to  light;  dry, 
immobile  eyeballs;  cold,  clammy  skin. 

The  signs  of  a  return  to  light  anesthesia,  or  the  second  stage,  after 
surgical  anesthesia  has  been  reached,  must  be  most  carefully  watched 
for  and  differentiated  from  those  of  deepening  anesthesia,  those  of  the 
fourth  or  dangerous  stage.  These  signs  of  returning  consciousness, 
in  the  order  of  importance  to  the  observing  anesthetist,  are :  increasing 
muscular  rigidity,  first  and  most  easily  noted  in  the  tightening  of 
the  relaxed  lower  jaw;  weak,  shallow  respirations;  lachyrmation 
with  movements  of  the  eyeballs;  attempts  to  swallow  and  vomit, 
pallor  of  the  skin;  dilated  pupils  which  react  to  light.  Unless  these 
signs,  singly  or  in  combination,  are  immediately  heeded,  and  more 
ether  administered,  the  patient  will  begin  to  cough  and  vomit,  move  on 


158  ANESTHESIA 

the  table,  and  cause  an  interruption  of  the  surgical  procedure.  The 
surgeon  will  be  rightfully  annoyed,  the  anesthetist  covered  with 
confusion. 

Caution. — Ether  in  liquid  or  vapor  form  is  exceedingly  inflammable. 
It  should  never  be  used  in  the  presence  of  or  proximity  to  a  flame. 
The  actual  cautery  should  never  be  brought  near  the  mouth  or  nose 
of  a  patient  under  ether  anesthesia. 


Fig.  81. — Esmarch  inhaler. 

Methods  of  Administering  Ether. — These  may  be  divided  into  the 
open  and  the  closed  methods.  In  the  former,  the  patient  does  not 
rebreathe  the  vapor  he  has  exhaled;  in  the  latter  a  variable  amount 
of  rebreathing  occurs  because  of  the  closed  apparatus  used. 

The  Open  Method. — The  two  chief  methods  are  the  so-called  drop 
method  where  ether  is  dropped  onto  layers  of  gauze  spread  over  a 
wire  frame  placed  over  the  mouth  and  nose  (Fig.  81);  and  the  cone 


Fig.  82. — Ether  cone:    newspaper  and  towel. 

method,  or  partially  open  method  where  ether  is  added  in  varying 
amounts  and  at  irregular  intervals  to  a  gauze  sponge  placed  at  the  top 
of  a  cone,  usually  made  with  a  cuff  of  newspaper  covered  with  towel 
or  muslin  (Fig.  82).  The  drop  method  is  the  safest  of  all  methods 
where  ether  alone  is  administered.  It  is  less  apt  to  cause  the  excite- 
ment stage,  and  because  of  the  large  amount  of  air  mixed  with  the 
ether  the  dangerous  fourth  stage  is  seldom  reached.     It  is  indicated 


ETHER  159 

in  children  and  in  patients  enfeebled  from  any  cause.  It  is  at  times 
difficult  to  use  with  alcoholic  or  stout  patients  because  of  the  difficulty 
in  concentrating  the  ether  vapor.  In  such  cases  the  closed  method, 
or,  where  a  closed  apparatus  is  not  available,  the  cone  method  is 
indicated. 

The  procedure  in  giving  drop  ether  is  as  follows:  Over  a  wire  mask 
of  the  Esmarch  type,  but  large  enough  to  cover  nose  and  mouth,  place 
six  to  ten  layers  of  surgeons'  gauze,  or  a  double  layer  of  stockinette 
material.  Clamp  this  in  place  with  the  wire  collar.  Moisten  a  towel 
folded  to  a  strip  four  inches  wide.  Cut  out  the  top  of  the  mouth  of 
an  ether  can.  Cut  a  small  groove  in  the  cork,  place  in  it  a  wick  of 
gauze  or  cotton  and  insert  the  cork  with  the  wick  into  the  mouth  of 
the  ether  can  so  that  the  ether  will  drop  at  the  rate  of  two  or  three 
drops  a  second.  Having  completed  these  preliminaries,  the  patient 
is  quietly  reassured  and  urged  to  breath  naturally  and  quietly.  Make 
sure  there  is  no  loose  article  in  the  patient's  mouth  such  as  false  teeth 
or  chewing  gum.  The  mask  is  placed  over  the  nose  and  mouth  and 
the  patient  breathes  air  a  few  times.  He  is  told  that  the  ether  will 
be  added  slowly,  and,  drop  by  drop,  it  is  allowed  to  fall  on  the  gauze 
above  the  mouth.  After  a  few  seconds  and  when  the  patient's  breath- 
ing is  regular,  the  damp  warm  towel  is  placed  around  the  top  of  the 
mask,  leaving  an  area  of  uncovered  gauze  an  inch  square.  As  the 
patient  becomes  more  accustomed  to  the  ether  the  rate  of  the  drop  is 
increased.  As  soon  as  the  respirations  deepen  and  the  skin  flushes, 
the  ether  is  dropped  on  rapidly  until  the  patient's  muscles  relax 
and  he  enters  the  third  stage.  If  the  drop  is  so  regulated  that  choking 
and  coughing  do  not  occur,  the  second,  or  excitement  stage,  can  be 
avoided.  As  soon  as  the  third  stage  is  reached  the  drop  is  slowed, 
enough  only  being  added  to  keep  the  patient's  jaw  relaxed  and  the 
breathing  regular. 

The  Closed  Method. — There  are  many  apparatuses  named  after  as 
many  anesthetists  for  carrying  out  this  method  which  is  really  the 
nitrous  oxide-ether  sequence.  All  of  these  have  in  common  a  face 
piece,  with  rubber  cushion,  above  this  a  cylinder  fitted  with  valves 
for  regulating  the  flow  of  nitrous  oxide  and  ether,  and  above  this  a 
rubber  bag  for  rebreathing.  Thomas  Bennett,  of  New  York  City, 
first  introduced  this  method  of  giving  the  gas-ether  sequence,  and  his 
apparatus  is  shown  in  Fig.  83. 

The  technic  for  giving  this  sequence  is  as  follows:  Inflate  the 
rubber  cushion  on  the  face  piece,  but  not  too  tightly.  Place  a  gauze 
strip  in  the  ether  chamber  so  that  it  is  filled  loosely  with  gauze.  Make 
sure  no  threads  or  loose  ends  project  between  the  valve  surface. 
Pour  three  or  four  drams  of  ether  into  the  gauze  in  the  ether  chamber. 
Close  the  ether  chamber  so  that  the  patient  will  not  smell  the  ether. 
Fill  the  gas  bag  with  nitrous  oxide  but  do  not  overdistend  it.  Having 
completed  these  preliminaries  outside,  enter  the  room,  quietly  reassure 
the  patient  and  advise  him  to  breathe  naturally.     Make  sure  there 


100 


ANESTHESIA 


are  no  loose  bodies  in  the  mouth.  Place  the  mask  quietly  over  the 
patient's  mouth  and  nose.  Let  him  breathe  air  a  few  times.  Turn 
on  the  gas  (if  the  bag  is  over  distended  the  rush  of  gas  will  frighten 
the  patient).  Have  the  patient  breathe  out  through  the  exhaling 
valves  several  times  to  rid  his  lungs  of  oxygen.  Then  turn  on  the 
rebreathing  valve  and  if  necessary  add  more  gas  to  the  bag  from  the 
cylinder.  If  the  face  piece  and  valves  are  air  tight,  after  eight  or  ten 
respirations  the  breathing  will  become  rapid,  deep  and  slightly  stertor- 


Fig.  83. — Bennett  inhaler  for  gas  and  ether. 


ous  and  the  patient  loses  consciousness.  At  this  point  begin  turning 
on  the  ether  valve,  very  slowly  at  first.  If  the  patient  chokes  or  shows 
any  catch  in  his  breathing,  turn  off  the  ether,  give  nothing  but  nitrous 
oxide  for  a  few  respirations  and  again  begin  gradually  with  the  ether. 
By  the  time  the  ether  valve  is  on  to  its  limit,  the  patient  should  be  in 
full  surgical  anesthesia.  After  that,  ether  is  added  to  the  ether 
chamber  in  dram  doses  every  two  minutes,  more  or  less,  according  to 
the  age  and  size  of  the  patient. 


INTRATRACHEAL   AND  ENDOPHARYNGEAL  INSUFFLATION     161 

When  properly  given,  the  advantages  of  the  nitrous  oxide-ether 
sequence  are  the  avoidance  of  subjective  sensations  of  choking  and 

distress  of  the  first  stage  and  the  struggling  or  cyanosis  of  the  second 
or  excitement  stage;  much  less  ether  is  used,  a  saving  usually  of  a 
quarter  to  a  half  of  the  amount  used  in  the  drop  method;  the  rapidity 
of  the  induction  of  surgical  anesthesia,  the  patient  usually  reaching  this 
stage  in  from  two  to  four  minutes. 

The  Cone  Method. — The  gauze  sponge  at  the  top  of  the  towel  cone 
is  sprinkled  with  ether,  the  cone  is  held  two  or  three  inches  above 
the  mouth  of  the  patient  and  is  gradually  lowered  over  the  mouth  and 
nose  as  the  ether  is  tolerated  and  breathing  deepens.  More  ether  is 
added  until  the  stage  of  surgical  anesthesia  is  reached,  when  only 
enough  is  added  to  continue  the  anesthesia. 

The  advantages  of  this  method  are  its  simplicity;  the  disadvantages 
are  the  greater  frequency  and  degree  of  excitement  stage  because 
of  the  concentrated  ether  vapor,  the  intermittent  addition  of  concen- 
trated ether  vapor  with  the  danger,  in  unskilled  hands,  of  reaching  the 
fourth,  or  overdose  stage. 

Anesthesia  by  Intratracheal  and  Endopharyngeal  Insufflation. — 
Intratracheal  Insufflation. — Meltzer  and  Auer  first  described  this 
method  in  1909.  They  discovered  that  proper  exchange  of  air  or  of 
ether  vapor  and  air  in  the  lungs  can  be  accomplished  by  a  continuous 
stream  of  vapor  passing  in  one  direction.  Their  apparatus,  and 
the  more  elaborate  ones  since  devised  by  Elsberg  and  Janeway, 
possess  the  following  features:  Air,  or  oxygen,  is  pumped  through  a 
tube  connected  with  a  mercury  monometer  and  a  bottle  or  jar  contain- 
ing ether,  into  the  trachea.  The  three  conditions  essential  to  success 
are:  (1)  the  tube  passing  into  the  trachea  must  be  of  a  size  less  than 
one-third  the  diameter  of  the  trachea,  (2)  the  stream  of  ether  vapor 
and  air  or  oxygen  must  be  interrupted  five  to  eight  times  a  minute  to 
permit  the  escape  of  carbon  dioxide  from  the  alveoli  of  the  lung,  (3) 
the  pressure  of  the  air-ether  vapor  must  not  exceed  20  mm.  of  mercury. 

Indications  for  Intratracheal  Insufflation. — (1)  In  thoracic  surgery 
it  prevents  the  collapse  of  the  lung  when  the  thoracic  cavity  is  entered 
by  maintaining  an  intra-alveolar  positive  pressure.  (2)  In  operations 
on  the  head  and  neck  where  it  is  desirable  to  have  the  anesthetist 
away  from  the  field  of  operation.  (3)  In  operations  on  the  mouth  and 
nasopharynx  and  larynx  where  there  is  a  probability  of  aspirating 
blood  or  septic  fluids.  The  stream  of  air  and  ether  continually  escaping 
from  the  larynx  blows  out  any  fluid  or  particles  that  might  enter  the 
larynx.  (4)  Insufflation  may  be  used  with  air  or  oxygen  alone  as  a 
method  of  artificial  respiration,  as  in  severe  morphine  or  opium 
poisoning. 

The  only  disadvantages  of  this  method  are  its  limitation  to  operative 
cases  in  a  hospital,  and,  what  is  most  important,  the  difficulty  and 
trauma  frequently  present  during  the  introduction  of  the  catheter 
into  the  larynx. 
11 


162  ANESTHESIA 

Endopharyngeal  Insufflation. — Dr.  Karl  Connell  in  1912  perfected 
this  method  and  with  it  determined  the  accurate  percentages  of  ether 
necessary  for  surgical  anesthesia  when  given  by  the  vapor  method 
either  endopharyngeally  or  endotracheally.  His  is  the  most  scientific 
work  that  has  ever  been  done  in  anesthesia.  To  quote  from  Dr. 
Connell's  description  of  the  method:  "The  delivery  is  established  after 
full  surgical  relaxation  has  been  secured  by  face  mask  methods.  .  .  . 
The  essential  feature  of  this  pharyngeal  method  is  that  a  volume  of 
air  is  insufflated  by  positive  pressure  into  the  lower  pharynx,  a  volume 
sufficient  to  provide  entirely  for  each  inspiration  without  any  air 
being  inhaled  by  nose  or  mouth  and  a  volume  bearing  a  known  per- 
centage of  ether  vapor  in  the  greatest  dilution  which  will  hold  that 
patient  evenly  and  safely  anesthetized  for  the  operation  in  hand. 
The  delivery  is  accomplished  by  preference  through  two  catheters 
inserted  one  through  each  nostril  a  distance,  on  the  average,  of  12 
cm.  The  catheters  selected  for  the  adult  are  size  18,  F,  soft  rubber, 
velvet-eye,  with  accessory  eyelet.  These  are  attached  to  a  Y-metal 
delivery  tube  with  bent  prongs  for  convenience  of  placement,  to  prevent 
angulation  and  to  hold  the  catheters  in  place.  This  Y-piece  is  attached 
to  the  forehead  with  adhesive. 

The  volume  insufflated  is  such  as  entirely  to  supply  the  needs 
of  inspiration  without  extraneous  dilution.  This  requires  18  litres  of 
air  per  minute  for  the  average  adult;  into  this  is  vaporized  the  ether." 

Connell  was  the  first  to  establish  scientifically  the  accurate  per- 
centages of  ether  necessary  for  surgical  anesthesia  when  given  by 
the  vapor  method  either  endopharyngeally  or  intracheally.  After 
analyzing  600  insufflation  anesthesias  in  the  Roosevelt  Hospital 
he  plotted  charts  from  a  composite  of  300  anesthesias  in  which  careful 
records  were  kept  of  ether  percentages  in  relation  to  the  stage  and 
degree  of  the  anesthesia. 

Connell  summarizes  the  essentials  of  endopharyngeal  anesthesia 
as  follows:  1.  The  ether  tension  in  the  arterial  blood  to  the  sensorium 
is  the  determining  factor  of  anesthetization. 

2.  The  tension  is  established  by  maintaining  in  the  alveolar  air 
during  preliminary  narcosis  an  ether  content  of  from  30  to  45  per  cent. 
by  weight  to  air  under  conditions  at  sea  level,  an  equivalent  in  pressure 
of  from  119  to  182  mm.  of  mercury.  During  the  early  stage  of 
anesthesia,  from  the  first  twenty  to  forty  minutes,  the  tension  must 
be  maintained  by  percentages,  scaling  from  26  down  to  15  per  cent. 
After  the  establishment  of  anesthetic  saturation  of  the  body  it  is 
maintained  at  about  the  latter  percentage,  the  equivalent  of  an  ether 
pressure  of  48  mm.  in  the  alveolar  air. 

3.  These  figures  probably  hold  for  the  entire  animal  kingdom, 
the  variable  factors  seen  in  ordinary  etherization  being  these:  (1) 
The  rapidity  with  which  the  entire  body  is  brought  to  complete 
anesthetic  saturation  as  determined  by  the  efficiency  with  which  the 
ether  tension  in  the  alveolar  air  is  maintained  by  fresh  delivery,  by 


INTRATRACHEAL  AND  ENDOPHARYNGEAL  INSUFFLATION      163 

diffusion  and  by  tidal  movement;  (2)  the  rapidity  of  blood  circulation; 
(3)  the  bulk  of  the  particular  body  to  be  saturated  and  the  capacity 
of  that  body  for  storage  and  destruction  of  the  ethyl  radical. 

4.  The  zones  of  anesthesia  above  and  below  this  saturation  or 
anesthetic  tension  point  are  already  well  established  for  man.     With 


Fig.  84. — Connell's  anesthetometer. 


absolute  certainty  as  to  the  outcome,  man  may  be  placed  in  an  ether 
atmosphere  of  the  percentage  of  ether  or  vapor  pressure  required  to 
produce  deep,  medium  or  light  anesthesia. 

5.  The  zone  of  surgical  relaxation,  i.  e.,  an  ether  pressure  of  45 
to  50  mm.  is  a  zone  for  many  hours  devoid  of  danger  by  ether 
intoxication. 


164  ANESTHESIA 

The  anesthetometer  is  an  apparatus  for  the  automatic  measuring 
and  mixing  of  vapors  and  gases  used  to  maintain  anesthesia  (Fig.  84). 
The  apparatus  consists:  (1)  of  a  gas  meter  as  the  measuring  and  mo- 
tive mechanism;  combined  with  (2),  an  ether  reservoir  from  which 
volatile  liquid  is  fed  in  accurately  adjusted  amounts;  into  (3),  a  vapor- 
izing chamber;  which  is  combined  (4)  with  a  trip-valve  by  which  gases 
in  any  quantity  may  be  mixed  in  accurate  percentage. 

By  the  use  of  this  apparatus  that  accuracy  of  dosage  in  the  admin- 
istration of  gaseous  drugs  so  long  deemed  necessary  for  liquids  and 
solids  is  secured.  By  the  use  of  the  anesthetometer,  particularly 
in  the  intratracheal  and  intrapharyngeal  delivery,  the  dosage  of 
gaseous  anesthetics  becomes  automatic,  yet  under  the  continuous 
observation  and  control  of  the  operator.  Thus  efficiency  and  safety 
in  prolonged  anesthesia  are  secured  and  the  shock  and  sequelae  of 
ether  anesthesia  are  largely  eliminated. 

Finally,  it  may  be  confidently  expected  that  by  the  accumulation 
of  accurate  data  such  as  this  instrument  makes  possible,  anesthesia 
by  pulmonary  absorption  will  be  placed  on  such  a  scientific  basis  as 
accurate  determination  of  dosage  alone  can  secure. 

Chloroform. — In  March  1847  Flourens  in  Paris  announced  that 
chloroform  had  an  anesthetic  action  on  animals  analogous  to  that  of 
ether.  As  a  result  of  this  discovery  Sir  James  Y.  Simpson,  of  Edin- 
burgh, introduced  chloroform  in  his  obstetrical  cases  and  it  soon, 
and  for  many  years  afterward,  replaced  ether  in  England  and  on  the 
Continent. 

Chloroform  is  the  most  dangerous  of  the  general  anesthetics  in 
common  use.  Hewitt  says,  "It  would  seem  that  we  have  in  chloro- 
form a  drug  which  is  a  powerful  protoplasmic  poison,  which  when 
given  in  toxic  quantities  leads  to  the  death  of  the  organism  not  because 
it  paralyzes  respiration — for  were  it  merely  a  respiratory  depressant, 
artificial  respiration  would  be  invariably  successful  in  averting  death 
— but  because,  as  recent  researches  have  shown,  it  markedly  depresses 
the  circulation."  The  exact  nature  of  the  paralyzing  action  as  regards 
the  part  of  the  circulatory  apparatus  affected  is  not  yet  determined. 
It  is  a  well-recognized  fact,  however,  that  the  margin  of  safety  between 
surgical  anesthesia  and  overdose  is  far  narrower  than  in  ether  or 
nitrous  oxide. 

Indications. — 1.  Obstetrical  cases  in  which  there  is  no  evidence 
of  toxemia  of  pregnancy.  In  pregnancy  the  heart  is  hypertrophied 
and  the  sphincters  are  active;  moreover,  full  surgical  anesthesia  is  not 
required. 

2.  In  the  very  young  and  very  old,  especially  as  an  introduction  to 
ether. 

3.  In  diseases  of  the  respiratory  system. 

4.  In  presence  of  high  blood-pressure  and  aneurysm. 

5.  In  operations  involving  the  respiratory  tract,  and  the  brain; 
also  where  the  actual  cautery  is  to  be  used  around  the  face. 


CHLOROFORM  165 

0.  In  tropical  countries  and  high  altitudes  it  is  indicated,  for  ether 
evaporates  too  readily. 

Contraindications. —  1.  Weak,  anemic,  septic  or  cachectic  patients. 

2.  J  n  status  lymphaticus. 

3.  In  minor  surgery,  where  a  safer  anesthetic  is  available. 

4.  In  all  operations  where  the  patient  is  in  the  sitting  posture. 

5.  In  diabetes  and  nephritis. 

After-effects. — The  immediate  after-effects  are  fewer  and  less  dis- 
agreeable than  with  ether,  but  the  late  effects,  so-called  acidosis,  as 
evidenced  by  presence  of  acetone  and  diacetic  acid  and  sugar  in  the 
urine,  indicate  serious  metabolic  disturbances  with  degenerative 
changes  in  the  parenchymatous  organs,  especially  the  liver. 

The  Administration**— The  drop  method  is  now  universally  used 
and  is  the  only  one  that  is  recommended  in  cases  where  chloroform 
is  indicated.  Before  starting  the  anesthetic  certain  precautions 
are  necessary.  The  patient  should  lie  in  a  horizontal  position;  there 
should  be  no  constriction  of  the  waist  or  neck;  the  chloroform  to  be 
used  should  be  of  guaranteed  purity  and  unexposed  to  light  or  to  air 
previous  to  the  administration.  It  should  be  dropped,  never  poured, 
from  the  bottle.  It  should  be  kept  stored  in  brown  bottles.  To 
prevent  burning  of  the  face,  the  lips,  nose  and  cheeks  should  be  covered 
with  a  thin  layer  of  vaseline  or  cold  cream.  The  eyes  should  be  covered 
with  gauze  or  a  handkerchief.  The  mask  should  be  of  the  Esmarch 
wire  frame  variety,  covered  with  two  layers  of  gauze  or  stockinette. 
Plenty  of  air  should  always  be  guaranteed  with  the  chloroform  vapor. 
Inasmuch  as  it  is  in  the  early  stages  of  chloroform  anesthesia  that  the 
accidents  occur,  particular  care  should  be  used  in  the  induction.  The 
mask  (Fig.  74)  should  be  held  one  or  two  inches  above  the  face;  two 
or  three  drops  of  chloroform  are  dropped  on  the  gauze  and  in  a  few 
seconds  two  or  three  more.  The  mask  is  then  lowered  over  the  nose  and 
mouth  and  as  the  patient  breathes  regularly  three  or  four  drops  are 
added  every  ten  seconds.  By  the  end  of  two  minutes  the  rate  should 
be  twenty  to  thirty  drops  every  minute.  If  the  patient  holds  his 
breath,  stop  the  drops  and  lift  the  mask.  After  the  patient  has 
relaxed,  surgical  anesthesia  should  be  maintained  with  half  the  amount 
that  was  necessary  at  the  time  full  surgical  anesthesia  was  induced. 
The  operation  should  never  begin  before  the  third  stage  or  surgical 
anesthesia  is  reached.  This  requires  four  to  ten  minutes  from  begin- 
ning of  induction.  During  this  stage  the  jaw  is  relaxed,  as  are  all  the 
muscles,  the  respirations  are  regular  and  full,  the  pulse  slows  down  to 
normal  rate,  and  the  skin  loses  its  high  color.  The  respiration  and 
pulse  are  the  most  important  signs  and  should  be  carefully  watched. 
Shallow  or  irregular  respirations,  an  irregular  pulse  or  a  pulse  below 
50,  and  extreme  pallor  are  danger  signals,  to  be  heeded  immediately 
by  raising  the  mask.  A  few  drops  of  ether  given  at  this  time  will 
usually  restore  the  previous  normal  condition  of  the  patient. 


166  ANESTHESIA 

Intravenous  Anesthesia. — In  the  last  decade  considerable  work  has 
been  done  in  an  effort  to  produce  a  uniform  and  safe  anesthesia  by 
introducing  solutions  of  drugs  directly  in  the  bloodvessels.  Although 
this  has  been  done  in  the  arteries  the  disadvantages  and  difficulties 
are  too  great  to  make  it  practical.  Intravenous  anesthesia  has  been 
successfully  carried  out  especially  in  the  European  clinics.  Burch- 
hardt  reports  a  series  of  250  intravenous  ether  anesthesias  with  very 
favorable  results.  Kummel  reports  130  cases  and  strongly  recommends 
this  form  of  ether  anesthesia  in  selected  cases.  Kiimmel  believes 
that  the  cases  of  thrombophlebitis  with  embolism  reported  by  Kuttner, 
Clairmont  and  Denk,  were  due  to  improper  technic  in  giving  the 
ether  intravenously.  Federoff  of  Petrograd  reports  several  hundred 
cases  of  intravenous  hedonal  anesthesia  with  favorable  results.  Burch- 
hardt  has  used  isopral  intravenously  in  several  hundred  cases.  It  is 
the  concensus  of  opinion  that  ether  is  safer  than  hedonal  or  isopral  for 
intravenous  injection,  inasmuch  as  the  dose  is  more  easily  controlled, 
is  safer  and  is  more  rapidly  eliminated  through  the  respiratory  tract. 
Kummel  recommends  it  for  the  following  groups  of  cases:  Head, 
face  and  neck  cases.  In  cases  that  have  become  greatly  reduced  or 
depleted  from  long-continued  disease  or  repeated  hemorrhages  the 
intravenous  saline  infusion  that  is  used  as  the  vehicle  for  the  ether 
acts  as  a  stimulant  to  the  heart  and  keeps  up  blood-pressure  throughout 
and  after  prolonged  anesthesia.  The  ether  can  be  given  in  much 
more  accurate  dosage  based  on  actual  measured  amounts  of  ether 
per  kilo  of  body  weight.  The  inflow  is  easily  controlled.  The  toxic 
dose  is  no  more  difficult  to  combat  than  with  inhalation  ether,  inasmuch 
as  the  excretion  in  both  cases  is  dependent  on  alveolar  interchange  of 
gases.  The  dangers  are  thrombosis  of  the  vein  and  embolism.  Kummel 
claims  this  is  entirely  avoidable  by  the  use  of  the  continuous  flow  of 
saline.  The  latter  is  a  distinct  disadvantage  in  prolonged  anesthesia, 
as  the  tissues  become  edematous  with  the  saline  content  of  the  blood. 
The  technic  as  described  by  Kummel  is  as  follows: 

All  patients  from  the  twentieth  to  sixtieth  year  are  given  a  dose  of 
morphine' i  grain,  scopolomine  y^y  grain  before  operation.  In  partial 
anesthesia  the  patient  is  placed  on  the  operating  table,  the  eyes  are 
covered  and  under  aseptic  precautions  the  median  basilic  vein  is 
exposed  and  the  cannula  introduced  as  for  a  saline  infusion.  In 
order  to  avoid  clotting  as  much  as  possible  a  continuous  stream  of 
saline  is  maintained.  This  is  done  by  using  two  separate  vessels, 
one  of  them  containing  the  ether  and  saline  solution,  the  other  a  4.1 
per  cent,  physiologic  salt  solution.  The  rubber  tubes  from  these 
vessels  are  joined  to  the  limbs  of  a  Y-piece  of  glass  tubing,  the  vertical 
limb  of  the  glass  is  connected  by  means  of  a  rubber  tube  with  the 
cannula  and  fitted  with  an  easily  regulated  stop-cock.  This  stop-cock 
makes  it  possible  to  inject  very  small  quantities  of  fluid  with  absolute 
uniformity.  When  a  quantity  of  ether-saline  mixture  sufficient  to 
establish  a  satisfactory  anesthesia  is  administered,  the  ether  mixture 


ANESTHESIA  BY  COLONIC  ABSORPTION  OF  ETHER       1G7 

is  shut  off  with  a  clamp  and  physiologic  salt  solution  is  slowly  injected 
until  the  reappearance  of  reflexes  again  calls  for  the  addition  of  the 
ether  mixture,  which  is  accomplished  by  reversing  the  clamp  to  the 
tube  leading  from  the  saline.  The  glass  containers  are  calibrated  so 
that  accurate  readings  can  always  be  made  of  the  relative  quantities 
of  ether  and  saline  solutions. 

Anesthesia  by  Colonic  Absorption  of  Ether. — Two  methods  have 
been  used,  the  older  method  of  colonic  insufflation  of  ether  vapor, 
the  more  recent,  the  method  of  introducing  either  mixed  in  olive  oil, 
the  so-called  oil-ether  method.  The  advantages  formerly  urged  for 
anesthesia  by  colonic  absorption  in  head,  neck,  and  mouth  operations 
have  been  obtained  in  the  safer  and  more  accurate  methods  of  intra- 
tracheal and  intrapharyngeal  anesthesia.  In  the  hands  of  such  men 
as  Sutton,  who  has  perfected  ether  vapor  colonic  anesthesia  and 
reported  the  best  results,  the  method  is  a  fairly  safe  one;  but  it  is  not 
a  safe  method  in  unskilled  hands,  and  it  is  far  more  difficult  to  deal 
with  overdosage  inasmuch  as  the  excess  of  ether  vapor  in  the  colon 
cannot  be  rapidly  eliminated.  The  same  objection  is  rightfully  made 
against  the  oil-ether  colonic  anesthesia. 

Gwathmy  reports  over  500  oil-ether  anesthesias  and  favors  the 
method.     His  conclusions  are  as  follows: 

1 .  One  of  the  greatest  advantages  of  the  method  is  that  the  anesthetic 
can  be  administered  to  the  patients  in  bed,  without  their  knowledge, 
thus  fulfilling  many  principles  of  anoci  association  as  enunciated  by 
Crile. 

2.  In  over  95  per  cent,  of  cases  there  has  been  no  eructation  of  gas 
during  anesthesia. 

3.  When  the  patient  has  been  in  fair  condition  there  has  been 
not  a  single  instance  of  colitis,  bloody  stools,  or  blood-streaked  returns. 

4.  The  oil-ether  narcosis  is  evenly  maintained  automatically. 

5.  Postoperative  vomiting,  nausea,  and  gas  pains  are  reduced  to  a 
negligible  quantity. 

6.  The  patient  recovers  consciousness  in  the  analgesic  state. 
Gwathmy's  technic  is  as  follows : 

Thorough  castor  oil  catharsis  the  night  before  operation,  followed 
in  the  morning  by  enema.  Preliminary  medication  of  chlorotone 
gr.  x,  or  paraldehyde,  2  oz.,  in  ^  oz.  of  olive  oil  by  rectum  an  hour 
before  operation.  Half  an  hour  before  operation  morphine,  gr.  f, 
is  given  hypodermically.  Ten  minutes  before  operation  the  oil-ether 
enema  is  started  wTith  patient  in  the  Sim's  position  in  his  own  bed. 
A  60  to  75  per  cent,  solution  of  ether  in  olive  oil  is  given  slowly,  using 
an  ounce  to  every  twenty  pounds  of  body  weight.  Eight  ounces  of 
the  75  per  cent,  mixture  will  cause  the  anesthesia  to  last  two  to  three 
hours.  No  more  than  eight  ounces  should  ever  be  given.  In  ten  to 
twenty  minutes  the  patient  is  in  full  surgical  anesthesia. 

To  relieve  overdose  symptoms  the  tube  in  the  rectum  is  opened 
and  the  solution  is  allowed  to  run  out. 


168  ANESTHESIA 

The  common  criticism  of  the  method  is  that  it  is  difficult  to  gauge 
the  correct  dose  for  operation,  which  may  be  short  or  long,  and  it  is 
more  difficult  to  prevent  overdosage. 

Treatment  of  Anesthetic  Shock. — The  anesthetist  must  constantly 
bear  in  mind  the  symptoms  of  overdose  and  of  anesthetic  shock. 
These  are  most  apt  to  appear  in  the  induction  stage  or  in  the  late 
stages  of  a  prolonged  operation  in  a  patient  of  low  vitality.  When 
the  patient  stops  breathing,  or  it  becomes  impossible  to  feel  his  pulse, 
or  the  color  becomes  a  dusky  gray,  the  anesthetist  must  act  quickly, 
but  calmly,  and  the  operators  must  stop  their  work  to  help  if  necessary. 
If  stopping  the  anesthetic  or  clearing  the  air  passages  fails  to  restore 
the  patient  other  measures  must  be  used  immediately. 

1.  Press  down  on  the  lower  sternum  or  give  the  chest  a  vigorous 
slap. 

2.  Lower  the  head. 

3.  Open  the  jaw  with  a  wooden  wedge;  then  apply  jaw  forceps  to 
keep  jaw  open,  and  draw  out  the  tongue  and  replace  it  rhythmically 
at  the  rate  of  IS  to  20  per  minute. 

4.  An  assistant  should  dilate  the  sphincter  ani. 

5.  If  these  measures  do  not  suffice,  use  artificial  respiration.  The 
anesthetist  grasps  the  elbows,  presses  them  firmly  against  the  patient's 
sides,  expelling  the  air  or  anesthetic  vapor  from  the  lungs ;  they  should 
be  held  with  pressure  against  the  chest  for  four  or  five  seconds.  The 
arms  are  then  abducted  above  the  head.  This  alternate  adduction 
and  abduction  of  the  arms  should  be  done  at  the  rate  of  15  per  minute. 
Massage  at  the  precordium  is  of  benefit  and  can  be  done  by  an  assistant. 

Local  Anesthesia. — Compression  of  nerve  trunks  and  local  appli- 
cation of  cold  to  produce  a  rather  poorly  defined  anesthesia  had  been 
known  for  centuries,  but  not  until  the  invention  of  the  hypodermic 
syringe  in  1853  by  Alexander  Wood  and  the  introduction  of  such  drugs 
as  cocaine  in  1884,  novocaine  in  1905,  was  local  anesthesia  made 
practical  and  efficient.  Although  in  recent  years  new  and  safer 
methods  of  administering  general  anesthetics  have  been  developed 
there  still  remains  a  large  class  of  surgical  cases  where  general  anes- 
thesia is  either  contra-indicated  or  unnecessary,  as  in  marked  valvular 
disease,  or  in  minor  surgical  operations.  Local  anesthesia  may  be 
used  in  such  cases  with  entire  satisfaction  to  both  patient  and  surgeon. 

Based  on  the  method  used,  local  anesthesia  may  be  accomplished  by : 

1.  Surface  application. 

2.  Infiltration. 

3.  Regional  injection  of  nerves. 

4.  Spinal  injection. 

5.  Intravenous  or  intra-arterial  injection. 

These  methods  and  the  materials  necessary  will  be  taken  up 
separately : 

1.  Surface  Application. — This  method  is  limited  to  the  mucous 
membranes  and  cannot  be  used  on  the  skin.     Cocaine  in  2  to  10  per 


INFILTRATION  169 

cent,  solutions  is  applied  on  a  cotton  swab  to  the  mucous  membrane 
to  be  anesthetized.     In  five  to  ten  minutes  the  area  will  be  painless. 

2.  Infiltration. — The  infiltration  method  is  the  most  widely  used, 
and  is  applicable  to  almost  any  surgical  field.  In  this  method,  because 
of  the  large  amount  of  fluid  necessary  to  produce  an  edema  of  the 
several  layers  of  tissue,  novocaine  in  \  to  1  per  cent,  solution,  with  a 
few  drops  of  adrenalin  chloride  to  make  a  1  to  20,000  solution  is  the  solu- 
tion of  choice.  It  is  far  less  toxic  than  cocaine  and  can  be  boiled  for 
purposes  of  sterilization.  The  syringe  used  should  be  a  high  grade  5  c.c. 
syringe,  with  socket  attachment  for  the  needles,  so  that  the  syringe 
can  be  easily  released  from  the  needle  for  refilling  purposes.  The 
tip  should  be  of  metal  and  accurately  ground  to  fit  the  needles.  At 
least  two  of  these  syringes  with  extra  needles  should  be  ready  for 
the  operation,  so  that  the  assistant  can  have  a  refilled  one  to  hand  the 
operator  as  soon  as  he  discards  the  empty  one.  The  patient  is  prepared 
as  for  any  operation,  but  the  method  should  be  carefully  explained 
to  him  so  that  he  will  not  be  terrified  at  the  idea  of  being  operated  on 
in  the  conscious  state.  He  should  be  wheeled  into  the  operating 
room  with  eyes  covered,  when  the  noise  and  hurry  of  the  preparation 
is  over.  Many  surgeons  precede  the  operation  by  a  hypodermic  of 
morphine  gr.  \  to  \.  This  allays  the  nervousness  and  puts  the  patient 
in  a  neutral  state  of  mind.  The  surgeon  must  remember  that  his 
anesthetized  field  is  a  limited  one  and  consequently  his  operative 
field,  and  he  must  be  far  more  careful  in  his  retraction  and  dragging 
on  tissues  in  and  near  the  wound  than  when  the  patient  is  under  general 
anesthesia.  He  must  remember  to  work  more  slowly,  deliberately 
and  more  carefully  than  when  the  patient  is  unconscious.  He  must 
remember  to  encourage  the  patient  from  time  to  time,  and  to  blame 
himself  if  the  patient  complains  of  pain. 

When  preparations  are  complete  the  surgeon  uses  a  small  hypodermic 
syringe  to  anesthetize  the  skin  around  the  first  needle  prick.  This 
first  needle  prick  should  be  the  only  one  felt  by  the  patient.  A  welt 
is  made  with  the  hypodermic  and  through  it  the  larger  needle  is 
introduced  and  the  line  of  incision  is  made  painless  by  making  a  series 
of  connecting  wheals  in  the  deeper  layer  of  the  skin.  Careful  anestheti- 
zation of  the  skin  is  essential  to  keep  the  patient's  confidence,  for 
once  the  skin  is  incised  the  deeper  tissues  are  rendered  painless  more 
easily.  The  vessels  and  nerve  trunks  are  sensitive.  Subcutaneous 
fat  in  itself  is  not.  The  parietal  peritoneum,  synovial  membrane 
and  periosteum  are  also  exquisitely  sensitive  and  should  always  be 
carefully  anesthetized.  After  the  skin  is  incised  each  layer  is  made 
edematous  by  a  series  of  wheals,  and  incised. 

By  this  method,  laparotomies,  amputations,  excisions  of  tumors, 
can  be  accomplished  if  the  proper  care  is  used  to  establish  anesthesia. 
Improper  syringes,  and  haste  and  carelessness  on  the  part  of  the 
surgeon  will  usually  result  in  pain  to  the  patient  and  chagrin  to  the 
surgeon. 


170  ANESTHESIA 

3.  The  Regional  Method. — -The  regional  method  has  been  elaborated 
by  Braun  who  has  used  it  very  extensively.  It  is  based  on  the  principle 
of  anesthetizing  the  sensory  nerve  trunk  or  trunks  supplying  the 
tissues  to  be  incised.  This  may  be  done  either  by  bathing  the  nerves 
with  the  anesthetic  (perineural)  or  by  injecting  the  fluid  directly 
into  the  nerve  substance  (endoneural).  An  accurate  knowledge  of 
the  sensory  nerve  supply  of  the  different  parts  of  the  body  surface  is 
essential  to  the  success  of  this  method.  For  the  details  of  this  work 
see  Braun's  monograph. 

To  prepare  a  J  per  cent,  solution  of  novocaine  with  1  to  20,000  adre- 
nalin dissolve  0.1  gram  of  novocaine  crystals  in  25  c.c.  of  normal  salt 
solution.  Add  1  c.c.  of  1  to  1000  solution  of  adrenalin  chloride.  Boil 
this  solution  for  two  minutes.     Serve  from  a  sterile  cup. 

4.  Spinal  Anesthesia. — The  injection  of  a  small  amount  of  a  2  per 
cent,  solution  of  cocaine  into  the  subarachnoid  space  of  the  lumbar 
spine  results  generally  in  a  more  or  less  complete  analgesia  of  the 
parts  below  this  point,  and  often  for  a  considerable  distance  above. 
This  method  of  producing  anesthesia  was  first  suggested  to  the  pro- 
fession by  Corning  in  1885,  but  was  not  extensively  used  for  surgical 
purposes  until  the  publication  of  Bier's  report  in  1899.  Since  that 
time  it  has  been  frequently  employed  for  operations  of  all  kinds  on 
the  lower  extremities,  the  male  and  female  genital  organs,  the  rectum, 
in  hernias,  and  in  some  laparotomies.  After  a  successful  injection 
insensibility  to  pain  is  generally  complete  in  from  six  to  ten  minutes. 
The  upper  limit  of  the  analgesia  is  usually  at  some  point  between  the 
umbilicus  and  pubes,  but  it  may  be  as  high  as  the  nipples,  or  even  the 
axilla?. 

Method  of  Injection. — The  cocaine  solution  should  be  prepared  by 
dissolving  the  cocaine  crystals  in  distilled  water  and  then  placing  a 
test-tube  containing  the  solution  in  boiling  water  for  two  minutes. 

The  lumbar  region  of  the  patient  should  be  prepared  as  for  any 
aseptic  operation,  and  the  patient  placed  in  Sim's  position,  with 
the  spine  well  arched  forward,  or,  as  preferred  by  many,  in  the  sitting 
posture,  with  the  elbows  resting  on  the  thighs.  A  slender  hypodermic 
needle  three  and  one-half  inches  in  length  should  be  introduced  at  a 
point  three-quarters  of  an  inch  to  the  outer  side  of  the  tip  of  the  fourth 
lumbar  spine,  and  carried  obliquely  inward  and  upward,  passing 
between  the  lamina;  of  the  fourth  and  fifth  lumbar  vertebra;  until  the 
subarachnoid  space  is  reached.  This  is  evidenced  by  the  appearance 
of  a  few  drops  of  clear  cerebrospinal  fluid  at  the  external  orifice  of  the 
needle.  After  the  escape  of  five  or  six  drops  the  syringe,  filled  with 
the  cocaine  solution,  is  screwed  to  the  needle,  and  from  8  to  15  minims 
of  a  2  per  cent,  solution  injected.  The  needle  is  then  withdrawn  and 
the  minute  cutaneous  wound  sealed  with  sterile  zinc  oxide  plaster  or 
collodion.  In  highly  nervous  individuals  it  is  often  desirable,  in  order 
to  distract  their  attention,  to  go  through  the  form  of  administering  a 
general  anesthetic  by  using  a  cone  moistened  with  alcohol  or  ether. 


LOCAL  VENOUS  ANESTHESIA  171 

It  should  be  remembered  that  an  appreciation  of  contact  remains  in 
these  cases — the  patient  may  feel  the  pressure  of  the  knife,  but  he 
experiences  no  painful  sensation. 

Spinal  cocainization  is  frequently  followed  by  severe  headache, 
vomiting,  and  fever,  which  persist  often  for  from  six  to  thirty-six 
hours.  Sometimes  these  symptoms  are  promptly  relieved  by  the 
hypodermic  injection  of  ^  grain  of  glonoin,  yts  grain  of  hyoscine 
hydrobromate,  or,  as  suggested  by  Kuster,  by  lumbar  puncture  and 
the  withdrawal  of  about  10  c.c.  of  fluid.  It  is  unsafe  to  make  the 
injection  above  the  second  lumbar  vertebra  on  account  of  the  danger  of 
wounding  the  cord  or  producing  hemorrhage. 

With  a  view  to  avoiding  the  unpleasant  after-effects  of  cocaine 
spinal  anesthesia,  many  surgeons  have  experimented  with  some  of 
the  newer  local  anesthetics.  Oehler  has  recently  reported  a  series 
of  1000  cases,  and  large  numbers  of  observations  have  been  made  by 
Kuster,  Holzbach,  and  others.  The  concensus  of  opinion  seems  to  be 
that  tropococaine  and  novocaine  have  advantages  over  cocaine  in 
that  they  are  less  toxic,  and  therefore  less  likely  to  be  followed  by 
headache  and  severe  vomiting.  Eucaine  and  stovaine  seem  to  be 
less  reliable  when  employed  in  this  manner.  Bier  and  others  have 
advocated  the  addition  of  a  small  amount  of  adrenalin  to  the  solution, 
which  delays  absorption,  prolongs  the  anesthesia  and  diminishes 
the  unpleasant  sequelae.  In  the  technic  of  administration  it  has 
been  suggested  that  it  is  well  to  withdraw  an  amount  of  cerebrospinal 
fluid  equal  to  the  amount  of  solution  ejected.  Huntington,  of  San 
Francisco,  who  has  had  an  extended  experience  with  tropococaine, 
dissolves  1  grain  of  the  drug  in  the  fluid  removed  from  the  spine  and 
immediately  reinjects  it. 

Temporary  and  complete  paralyses  have  been  reported  following 
spinal  anesthesia,  and  a  sufficient  number  of  deaths  have  followed 
its  employment  to  demonstrate  that  the  method  in  perfectly  healthy 
individuals  is  more  dangerous  than  the  employment  of  general 
anesthesia. 

Spinal  anesthesia  is  to  be  recommended  only  in  cases  in  which 
positive  contra-indications  exist  to  the  use  of  the  other  anesthetics, 
and  occasionally  in  emergencies  in  which  a  skilled  assistant  is  not 
available  or  when  other  anesthetics  cannot  be  obtained. 

5.  Local  Venous  Anesthesia. — For  producing  anesthesia  in  operations 
on  the  extremities  Bier,  in  1908,  described  his  method  of  anesthesia 
of  an  entire  extremity  by  injecting  novocaine  into  the  superficial 
veins.  The  technic  is  as  follows:  The  extremity  is  elevated  and 
tightly  bandaged  with  an  Esmarch  bandage  to  a  point  below  the  site 
of  the  vein  selected  for  the  introduction  of  the  anesthesia.  At  a 
distance  of  10  to  25  cm.  above  this  bandage  a  second  is  applied.  Into 
the  segment  of  veins  between  these  Esmarch  bandages  40  to  50  c.c. 
of  a  0.5  per  cent,  solution  of  novocain,  without  adrenalin,  is  injected, 
either  directly  through  the  skin  and  vessel  wall,  or  through  the  wall 


172  ANESTHESIA 

of  an  exposed  vein.  Seventy  to  eighty  c.e.  may  be  injected  into  the 
internal  saphenous  vein  for  operations  on  the  leg.  The  tissues  in 
immediate  proximity  to  the  injected  veins  are  anesthetized  immediately 
and  directly;  the  tissues  of  the  remainder  of  the  limb  distal  to  the  upper 
bandage  are  anesthetized  in  8  to  10  minutes,  indirectly,  by  the  solution 
bathing  the  nerve  trunks  supplied  by  vessels  communicating  with 
the  network  of  superficial  veins  containing  the  novocaine. 

This  method  has  distinct  advantages  in  operations  on  the  extremities 
where  local  infiltration  is  difficult,  too  extensive  or  productive  of 
edematous  tissues.  It  is  contra-indicated  in  gangrene  of  the  senile  or 
diabetic  type. 

ANOCI  ASSOCIATION. 

This  term  has  been  applied  by  Crile,  of  Cleveland,  to  the  technic 
of  combined  local  and  general  anesthesia  designed  to  minimize  to 
the  least  possible  degree  the  shock  in  surgical  procedures.  This 
technic,  which  is  elaborate,  requires  the  most  painstaking  effort 
and  patience  on  the  part  of  the  surgical  staff  from  the  time  the  patient 
enters  the  hospital  to  his  discharge;  but  the  results  as  obtained  by 
Crile  and  his  assistants  more  than  justify  the  extraordinary  measures 
used  in  this  surgical  treatment.  Based  on  the  theory  that  surgical 
shock  is  the  result  of  centripetal  nocuous  nerve  impulses,  every  step 
in  the  technic  of  anoci  association  is  designed  to  prevent  the  incep- 
tion of  injurious  nerve  impulses  or,  where  they  are  unavoidable, 
to  prevent  such  impulses  from  reaching  the  sensorium  of  the  patient. 
Every  effort  is  made  to  avoid  extensive  operation  in  the  presence 
of  predisposing  causes  of  shock  such  'as  hemorrhage,  cachexia,  acidosis, 
fear.  An  attempt  is  made  to  remove  these  predisposing  causes 
whenever  possible.  Where  nocuous  impulses  are  avoidable,  such  as 
pain,  this  is  prevented  first  by  anesthetizing  the  tissues  to  be  incised 
by  local  novocaine  and  urea-quinine  infiltration;  secondly,  by  the 
relatively  non-toxic  general  anesthesia  of  nitrous  oxide-oxygen.  The 
technic  as  carried  out  by  Crile  is  as  follows: 

The  patient  is  given  a  hypodermic  of  morphine  gr.  \,  scopolomine 
gr.  tytt,  an  hour  before  operation.  In  the  operating  room,  or  if  neces- 
sary because  of  dread  of  operation,  in  the  patient's  room,  nitrous 
oxide-oxygen  anesthesia  is  given.  The  line  of  incision  and  tissue 
immediately  adjacent  to  the  incision  are  infiltrated  with  \  per  cent, 
solution  of  novocaine,  followed  by  \  per  cent,  of  quinine  and  urea 
hydrochloride  into  the  tissues,  2-3  cm-  away  from  the  planes  of  incision. 
Every  effort  is  made  to  minimize  trauma  and  to  incise  only  such 
tissues  as  have  been  anesthetized. 

In  exophthalmic  goitre  cases,  where  fear  is  such  a  predisposing  cause 
to  shock,  a  special  effort  is  made  to  keep  the  patient  quiet  mentally 
and  physically,  and  a  special  technic  is  used  by  which  the  patient  is 
given  preliminary  treatments  of  small  amounts  of  nitrous  oxide  and 


ANOCI  ASSOCIATION  173 

oxygen  for  several  mornings,  a  bandage  is  kept  on  the  neck  and  every 
effort  is  made  to  have  the  patient  regain  consciousness,  after  the 
operation,  in  the  same  surroundings  and  in  the  same  mental  state  as 
on  previous  mornings.  Morphine  is  used  freely  in  these  cases  to  dull 
the  sensorium,  and  place  the  patient  in  a  neutral  mental  state. 

It  must  be  thoroughly  understood,  however,  that  to  use  the  technic 
of  anoci  association  successfully,  a  thoroughly  trained  staff  of  surgeons 
and  nurses,  willing  and  anxious  to  co-operate  in  minimizing  nocuous 
nerve  impulses,  not.  only  in  the  operating  room  but  in  the  entire 
hospital  from  the  time  the  patient  enters  until  he  leaves,  is  absolutely 
essential. 


CHAPTER  IX. 
TREATMENT  OF  POSTOPERATIVE  CONDITIONS. 

SHOCK. 

For  the  etiology,  diagnosis,  and  prognosis  of  shock  the  reader  is 
referred  to  Chapter  VI.  Here  we  will  consider  only  the  postoperative 
treatment. 

Active  Treatment  of  Shock. — The  indication  to  be  met  is  the  exhaus- 
tion of  the  brain  centres  and  cortical  cells,  and  this  is  accomplished  by 
two  means — rest  and  renewed  blood  supply.  Cerebral  anemia,  due  to 
splanchnic  dilatation,  although  not  the  cause,  is  a  condition  constantly 
present.  To  overcome  this  cerebral  anemia  the  following  measures 
should  be  taken: 

1.  Lower  head  of  the  bed. 

2.  Apply  external  heat  to  extremities. 

3.  Bandage  the  extremities. 

4.  Apply  pressure  to  the  abdomen  when  possible  by  means  of  a 
tight  abdominal  binder. 

To  constrict  the  splanchnic  vessels,  give  a  hot  colon  irrigation. 
If  these  measures  prove  unavailing,  give  an  intravenous  infusion  of 
normal  salt  solution,  300-500  c.c,  T.  105°,  to  which  is  added  adrenalin 
1  to  1000,  Tflxv-xxx.  The  adrenalin  should  be  thoroughly  mixed  in 
the  salt  solution  before  the  solution  passes  into  the  vein.  This  is  very 
important,  as  sudden  death  has  occurred  by  injecting  the  adrenalin 
into  the  vein  or  into  the  conducting  tube  near  the  vein. 

If  a  donor  is  available,  whose  blood  has  been  tested  previously  to 
determine  the  question  of  hemolysis  and  agglutination,  blood  trans- 
fusion is  the  ideal  means  of  overcoming  the  shock,  for  by  this  means, 
both  the  fluid  and  the  nutriment  to  the  exhausted  cells  is  supplied 
at  the  same  time. 

Adrenalin  is  the  only  drug  that  can  be  logically  used  in  shock.  It 
causes  a  definite  constriction  of  the  dilated  splanchnic  vessels  and  over- 
comes the  cerebral  anemia  by  giving  the  heart  blood  to  pump  into  the 
depleted  areas.  Stimulants  to  the  exhausted  vital  centres  are  not 
only  of  no  definite  value  but  actually  are  harmful,  in  that  they  stimu- 
late exhausted  cells.  Far  better  supply  blood,  carrying  nutriment  to 
the  brain  centres,  and  rather  than  overstimulate  them  with  strychnine, 
put  them  at  rest  by  means  of  a  small  dose  of  morphine  so  that  the 
exhaustion  can  be  overcome.  This  is  especially  true  if  the  afferent 
impulses  causing  the  exhaustion  of  the  cortical  cells  are  still  passing 


HEMORRHAGE  175 

up  to  them.  This  is  often  the  case  in  recently  injured  patients,  as  a 
result  of  severe  burns  or  crushing  accidents,  or  in  patients  suffering 
from  a  spreading  peritonitis  following  rupture  of  a  viscus  as  in  gun- 
shot wounds  of  the  abdomen. 

In  treatment  of  postoperative  complications,  one  of  the  most  com- 
mon but  important  differential  diagnoses  that  has  to  be  made  before 
treatment  can  be  started  is  the  differential  diagnosis  of  shock  and 
hemorrhage.     This  is  given  in  the  chapter  on  Shock. 

HEMORRHAGE. 

Postoperative  hemorrhage  is  usually  divided  into:  (1)  primary; 
(2)  delayed;    (3)  secondary. 

Primary. — Prophylaxis. — Careful  hemostasis  should  be  maintained 
during  the  operation. 

Active  Treatment. — Find  bleeding  point,  or  if  necessary  pack  with 
gauze  when  the  vessel  cannot  be  ligated. 

Delayed. — Prophylaxis. — Be  sure  that  all  bloodvessels  are  ligated. 
On  large  vessels  use  chromic  ligatures.  Be  sure  to  tie  collateral 
branches  that  may  have  been  cut. 

Active  Treatment. — Active  treatment  of  hemorrhage  may  be  divided 
into  symptomatic  or  expectant,  and  operative;  the  resort  to  the  latter  is 
determined  by  the  severity  of  symptoms  indicating  the  degree  of  hemor- 
rhage and  the  failure  of  expectant  measures  to  control  the  symptoms. 

Expectant. — Try  to  determine  site  of  bleeding.  Examine  the  dress- 
ing, and  observe  especially  whether  there  is  evidence  of  fresh  bright 
blood,  and  if  the  blood  stain,  if  present,  is  spreading.  A  mere  staining 
with  pink  colored  fluid  is  often  present  with  an  oozing  exudate,  or  salt 
solution  left  in  the  peritoneum.  If  bleeding  is  found,  and  can  be 
controlled  by  a  tourniquet,  apply  it  until  bleeding  vessels  can  be 
ligated,  or  if  in  a  superficial  wound,  pack  with  gauze  as  aseptically  as 
possible.  If  the  case  is  a  celiotomy,  examine  dressings  and  drains. 
If  still  in  doubt,  look  for  dulness  in  flanks  and  shifting  dulness.  Vaginal 
examination  or  rectal  may  disclose  fluid  in  pelvis. 

If  hemorrhage  cannot  be  found  and  patient  is  not  growing  pro- 
gressively worse,  or  while  preparing  for  operation: 

Lower  head  of  bed;  give  morphine  gr.  |  hypodermically ;  apply  exter- 
nal heat;  give  patient  plenty  of  air.  Quiet  is  essential.  If  the  symp- 
toms of  internal  concealed  hemorrhage  continue  and  fail  to  respond 
to  above  treatment,  an  exploratory  operation  is  indicated.  The 
anesthetic  should  not  be  started  before  everything  is  ready  for  begin- 
ning the  operation.  Ether  by  the  drop  method  is  far  preferable  to 
chloroform.  Nitrous  oxide  probably  raises  the  blood-pressure  too  much. 

The  bleeding  point  should  be  found  as  quickly  as  possible,  tied  or 
clamped,  the  clamps  being  left  in  the  wound  if  necessary;  or  if  the 
bleeding  point  cannot  be  caught,  the  bleeding  area  should  be  packed 
with  gauze.     In  packing  gauze  in  the  abdomen,  protect  the  intestines 


176  TREATMENT  OF  POSTOPERATIVE  CONDITIONS 

from  the  gauze  as  far  as  possible  with  rubber  dam,  or  by  coating 
the  gauze  from  the  packed  bleeding  area  up  to  the  skin  surface  with 
albolene  or  vaselin.  This  is  to  prevent  the  extensive  adhesions  which 
form  when  gauze  comes  in  contact  with  the  peritoneum. 

As  little  delay  as  possible  should  be  incurred  in  returning  the  patient 
to  the  ward.  If  possible,  blood  transfusion  should  be  done  in  the 
operating  room  after  the  bleeding  has  been  controlled.  Transfusion 
is  being  used  more  and  more  in  modern  hospitals,  and  by  means  of  the 
methods  already  described  any  hospital  staff  can  carry  out  the  pro- 
cedure if  a  donor  can  be  found.  In  emergencies  a  near  relative  can 
act  as  donor  even  without  the  preliminary  tests  for  hemolysis  and 
agglutination.  (According  to  recent  investigations  of  the  Bacteriologi- 
cal Department  of  Columbia  University  the  chances  of  hemotysis  and 
agglutination  are  exceeding  small  if  a  blood  relative  is  used  as  donor.) 

After  the  hemorrhage  has  been  controlled  and  if  transfusion  is  not 
feasible  the  treatment  is  the  same  as  for  shock.  But  here  replenishing 
the  depleted  tissues  with  fluid  is  of  even  greater  importance.  Hypo- 
dermoclysis  is  the  method  of  choice.  It  can  be  used  in  cases  where 
hemostasis  is  not  assured,  and  where  the  blood  volume  can  be  gradually 
increased  without  raising  the  blood-pressure. 


POSTOPERATIVE  PNEUMONIA. 

Prophylaxis. — Prophylaxis,  as  far  as  the  surgeon  is  concerned,  is  by 
far  the  most  important  part  of  the  subject  of  the  treatment  of  post- 
operative pneumonia. 

1.  Avoid  ether  anesthesia  in  patients  having  pulmonary  disease — 
especially  acute  bronchitis  and  tuberculosis;  in  old  patients;  in  acute 
or  chronic  alcoholic  patients.  It  is  exceedingly  important  to  use 
pure  ether.  It  should  be  of  the  best  standard  grade,  guaranteed  free 
from  aldehyds  and  water.  It  should  not  be  used  after  standing 
for  any  length  of  time  in  an  opened  tin.  Wire  masks  or  face  pieces 
of  anesthesia  apparatuses  should  be  sterilized  before  using  them. 

2.  In  operations  on  the  mouth,  nasopharynx  and  larynx  prevent  as 
far  as  possible  the  ingress  of  blood  or  septic  material  from  the  naso- 
pharynx into  the  trachea.  This  is  best  accomplished  by  intra- 
tracheal insufflation  anesthesia,  or,  where  this  is  impossible,  by  packing 
the  anterior  pharynx  and  giving  intrapharyngeal  anesthesia  through 
tubes  introduced  through  the  nose  into  the  pharynx. 

3.  Avoid  vomiting  in  the  induction  of  and  during  the  anesthesia. 
If  the  patient  vomits,  keep  the  head  turned  to  one  side  and  prevent 
the  aspiration  of  vomitus.  This  should  be  particularly  emphasized 
when  the  patient  has  left  the  operating  table  and  is  coining  out  of  the 
anesthesia  on  the  way  to  the  ward,  or  while  in  the  bed  in  the  ward. 
Until  he  has  recovered  his  laryngeal  reflex,  the  patient  should  be 
watched  by  a  nurse  assigned  to  that  duty. 


RENAL  COMPLICATIONS  177 

4.  Avoid  unnecessary  exposure  of  the  patient  in  the  operating  room, 
on  the  way  to  the  ward,  and  in  the  ward  while  recovering  from  the 
anesthesia.  The  patient  should  be  wrapped  in  blankets  prior  to 
removal  to  the  ward  and  should  be  placed  in  a  warm  "ether  bed" — 
one  previously  warmed  and  kept  warm  with  hot-water  bottles.  Hot- 
water  bottles  should  never  be  placed  next  to  the  patient's  skin.  A 
towel  or  blanket  should  be  wrapped  around  the  bottle.  Severe  burns 
result  when  this  rule  is  disregarded. 

5.  Old  or  feeble  patients  should  not  be  allowed  to  lie  on  their  backs 
for  more  than  a  few  hours  at  a  time.  They  should  be  frequently 
turned  and  made  to  assume  semi-recumbent  positions  with  back-rests. 
This  avoids  the  so-called  hypostatic  form  of  pneumonia. 

Active  Measures. — These  depend  on  the  type  of  pneumonia  present. 
In  the  capillary  pneumonia  where  there  is  a  marked  bronchitis  present, 
the  patient  should  be  kept  in  a  warm  moist  atmosphere,  if  necessary 
in  a  croup  tent.  In  bronchopneumonia  type  the  patient  is  more 
comfortable  and  is  more  easily  cared  for  in  the  ward  near  an  open 
window.  In  cases  where  there  is  frank  consolidation,  with  signs  and 
symptoms  of  lobar  pneumonia,  and  cyanosis  due  to  toxemia,  and  with 
labored  breathing,  out-door  treatment  is  indicated.  The  treatment 
of  such  cases  is  the  same  as  in  medical  cases,  largely  symptomatic. 
It  is  seldom  that  the  treatment,  as  far  as  poulticing,  cupping  and 
drugs  are  concerned,  cannot  be  followed  as  in  medical  cases. 


RENAL  COMPLICATIONS. 

These  can  be  grouped  under  two  heads:  Those  giving  symptoms 
of  kidney  insufficiency,  usually  the  result  of  a  pre-existing  nephritis; 
and  those  which  develop  with  or  without  operation  as  a  result  of 
pyogenic  infection  of  the  kidney  or  kidneys,  secondary  to  a  pyogenic 
infection  elsewhere  in  the  body.  Predisposing  factors  to  both  of  these 
groups  of  kidney  complications  are  the  diminished  fluid  intake,  purging 
and  profuse  sweating  present  during  the  few  hours  preceding  and 
following  operation,  also  the  loss  of  fluid  associated  with  hemorrhage 
and  temperature,  and  by  the  irritating  action  of  the  common  anes- 
thetics— ether  and  particularly  chloroform. 

The  prophylaxis  is  based  on  the  elimination  of  these  factors.  In 
all  cases  before  operation,  fluids,  especially  water,  should  be  given  in 
generous  quantities.  If  there  is  any  evidence  of  a  nephritis  before 
operation,  or  if  the  patient  is  septic,  prophylaxis  should  be  directed 
along  these  lines : 

1 .  As  in  all  ante-operative  cases,  here  especially  should  water  be  given 
and  one  or  two  colon  irrigations  of  tap  water,  three  gallons,  T.  115°, 
before  operation.  If  during  or  after  operation  there  has  been  bleeding, 
give  colon  irrigations  t.  i.  d.  three  gallons,  T.  115°,  or  a  hypodermoclysis 
of  normal  saline,  500  to  800  c.c,  T.  105°,  b.  i.  d.  Avoid  exposure  of  the 
12 


178  TREATMENT  OF  POSTOPERATIVE  CONDITIONS 

patient  to  dampness  and  cold,  especially  while  recovering  from  the 
anesthesia. 

2.  Never  use  chloroform,  and  if  nitrous  oxide-oxygen  is  available 
as  an  anesthetic  and  can  be  given  competently,  do  not  use  ether. 

3.  Watch  the  amount  of  urine,  and  make  daily  urinalyses. 

Active  Treatment. — If  suppression  threatens,  give  hot  colon  irriga- 
tions every  six  hours.  Apply  counter-irritation  to  both  lumbar 
regions  by  use  of  mustard  paste  or  cupping.  Give  tincture  of 
digitalis,  1T|x,  t.  i.  d. 

If  anuria  is  present,  besides  the  above  measures,  use  hot  packs 
every  twelve  hours.  Rely  on  the  diaphoresis,  colon  irrigations  and 
cupping. 

To  prevent  pyogenic  infection  of  the  kidneys  in  presence  of  sepsis 
elsewhere,  keep  up  the  water  intake,  give  urotropine  gr.  xv,  t.  i.  d. 
Be  very  careful  to  prevent  a  cystitis  if  catheterization  is  necessary. 
If  a  suppurative  nephritis  develops  operation  may  be  indicated. 

TREATMENT  OF  DISCOMFORT  FOLLOWING  OPERATION. 

Under  the  term  discomfort  may  be  grouped  several  symptoms 
which  are  present  in  varying  degree  in  every  patient  that  has  undergone 
a  severe  surgical  operation.  Usually  present  only  for  the  first  twenty- 
four  hours  and  in  a  bearable  degree,  in  some  patients  one  or  several 
of  these  symptoms  may  amount  to  a  serious  condition,  and  must  be 
classed  as  a  definite  postoperative  complication.   These  symptoms  are : 

1.  Pain: 

(a)  Due  to  the  operative  wound  or  operative  manipulations. 

(b)  Headache. 

(c)  Backache. 

(d)  Gas  pains  or  abdominal  distention. 

2.  Restlessness  and  sleeplessness. 

3.  Nausea  and  vomiting. 

4.  Thirst. 

The  treatment  of  these  will  be  considered  separately,  but  it  is 
necessary  at  this  point  to  warn  against  the  abuse  of  the  drug  that  gives 
the  greatest  relief  during  the  first  few  days  after  operation,  i.  e., 
morphine.  Too  frequently  does  the  busy  interne  or  surgeon  fail  to 
get  at  the  cause  of  the  patient's  discomfort,  and  in  his  haste  or  desire 
to  keep  his  patient  quiet  orders  morphine,  hypodermically,  to  be 
repeated  at  the  discretion  of  the  nurse,  and  believes  that  he  has  done 
his  duty.  Instead  in  many  cases  he  has  done  actual  harm,  and,  by 
repeating  his  mistake,  insidiously  establishes  a  craving  for  morphine 
that  often  means  a  wrecked  life  for  the  patient  after  leaving  the 
hospital.  The  careless  and  repeated  prescribing  of  morphine  after 
operation  cannot  be  too  strongly  condemned.  After  operation  the 
patient  should  be  brought  immediately  to  his  room,  or  to  a  recovery 
room  where  he  is  placed  in  an  "ether  bed."     As  soon  as  possible  the 


TREATMENT  OF  DISCOMFORT  FOLLOWING  OPERATION      179 

room  should  be  darkened,  made  quiet  and  only  the  nurse  or  a  near 
relative  should  remain  in  the  room.  The  patient's  eyes  should  be 
covered  with  a  damp  compress,  and  if  he  is  regaining  consciousness 
and  is  beginning  to  be  noisy  or  excited,  a  quiet  reassurance  on  the  part 
of  the  nurse  or  parent  that  the  operation  is  successfully  completed, 
and  advice  to  remain  quiet  and  go  to  sleep  will  in  the  majority  of 
cases  of  ether  anesthesia  have  a  soothing  effect  on  the  patient.  Stupid 
with  the  ether  he  falls  asleep,  and  in  a  variable  time  begins  to  stir 
with  pain.  Now  is  the  time  for  the  hypodermic  of  morphine,  for 
if  it  is  given  after  an  hour  or  two  following  operation  the  reflexes  are 
active,  especially  the  laryngeal,  and  if  patient  vomits  he  does  not 
aspirate  septic  material.  The  morphine  at  this  time  usually  saves  a 
useless  previous  dose  *of  it.  The  amount,  even  in  peritonitis  cases, 
should  be  large  enough  to  insure  rest  and  quiet  and  sleep  for  several 
hours;  gr.  f  is  the  usual  adult  dose. 

The  severe  wound  pain  can  be  minimized  by  care  during  the  opera- 
tion in  the  retraction  and  manipulations  of  the  surgeons.  It  is  not 
yet  well  established  that  quinine  urea  hydrochloride  injected  into  the 
tissues,  on  either  side  of  the  planes  of  incision,  prevents  pain  for  several 
days,  but  in  the  hands  of  some  surgeons  it  apparently  prevented 
much  of  the  postoperative  pain. 

The  headache  of  the  first  twenty-four  hours  is  almost  always  due 
to  the  anesthetic  and  an  empty  stomach.  It  certainly  is  more  marked 
after  ether  than  after  nitrous  oxide-oxygen  anesthesia.  It  is  frequently 
relieved  by  placing  ice  compresses  on  the  forehead  with  an  ice  cap 
placed  against  the  top  of  the  head.  Sometimes  menthol  gives  great 
relief  when  rubbed  on  the  forehead. 

Backache  is  almost  always  the  result  of  the  patients'  being  in  the 
unconscious  extremely  relaxed  condition,  lying  one  to  two  hours  on  a 
metal  or  glass-top  operating  table.  This  relaxation  of  the  trunk 
muscles  throws  the  strain  on  the  intervertebral  ligaments.  The 
strain  on  these  ligaments  is  accentuated  by  the  customary  method  of 
raising  a  patient  by  the  small  of  the  back  from  the  operating  table 
for  the  adjustment  of  abdominal  or  hernial  binders.  The  best  treat- 
ment is  prophylactic.  Do  not  operate  on  a  patient  unless  he  is  provided 
with  an  air  or  elastic  cushion  that  fits  the  lumbar  curve  of  the  vertebral 
column.  Insist  on  the  orderlies  or  assistants  lifting  the  patient  in 
such  a  way  as  to  keep  the  body  horizontal.  For  the  treatment,  after 
backache  has  become  a  marked  symptom,  the  best  and  most  gratifying 
measure  is  to  make  a  large,  very  thick  hot  flaxseed  poultice.  Let  the 
patient  lie  on  this  so  that  the  poultice  fits  the  entire  lumbar  region 
on  both  sides.     It  can  be  renewed  if  necessary. 

The  so-called  gas  pains  usually  appear  at  the  latter  part  of  the  first 
twenty-four  hours,  and  are  in  reality  a  form  of  postoperative  distention. 
For  the  pain  of  this  distention  atropine  gr.  y^j  hypodermic-ally  is 
often  valuable.  Where  morphine  is  contra-indicated,  trivalen  is  very 
effectual  and  has  the  same  analgesic  effect.     (See  treatment  of  Ileus.) 


180  TREATMENT  OF  POSTOPERATIVE  CONDITIONS 

Restlessness  and  Sleeplessness. — The  restlessness  and  sleeplessness 
are  always  present,  but  much  more  marked  in  some  and  for  a  greater 
length  of  time  than  in  others.  The  nervous  temperament  and  nervous 
condition  of  the  individual  has  as  much  to  do  with  these  symptoms  as 
does  pain.  After  the  first  night  with  use  of  morphine  or  of  trivalen 
if  necessary,  the  patient  should  be  given  sodium  bromide  gr.  xxx  by 
rectum  t.  i.  d.,  and  everything  should  be  done  to  relieve  apprehension, 
nervousness  and  worry.  If  this  is  not  successful  rather  than  give 
morphine,  which  has  probably  been  demanded,  give  paraldehyd  \  oz. 
to  1  oz.  in  2  oz.  of  water  by  rectum. 

Thirst. — Predisposing  causes  are  limited  fluid  intake  just  before 
and  after  operation,  purging,  loss  of  blood  before  and  after  opera- 
tion, profuse  sweating  of  the  recovery  from  ether  anesthesia,  high 
temperature  associated  with  the  patient's  disease,  prolonged  pyloric 
obstruction,  depletion  from  any  cause;  ether  anesthesia  is  probably 
the  most  potent  predisposing  cause.  Prophylaxis:  Eliminate  as 
far  as  possible  the  predisposing  causes.  Urge  the  patient  to  drink 
plenty  of  water  to  within  two  hours  of  operation,  if  necessary  give 
colon  irrigations  or  hypodermoclyses.  If  much  fluid  has  been  lost,  if 
the  ether  anesthesia  was  prolonged  or  if  the  patient  has  a  temperature, 
give  the  patient  a  hypodermoclysis  while  still  under  the  influence  of 
the  ether.  Following  operation,  with  the  mouth  and  tongue  furred 
and  dry,  unless  especially  contra-indicated,  give  water  as  soon  after 
operation  as  it  is  requested.  Cracked  ice  should  be  avoided  as  it 
intensifies  the  thirst.  If  the  patient  has  been  accustomed  to  alcoholic 
drinks  and  is  complaining  bitterly  of  thirst,  a  high  ball  of  whisky 
and  soda  will  be  pronounced  the  best  drink  the  patient  ever  had. 
Weak  tea  is  at  times  very  much  appreciated. 

Nausea  and  Vomiting. — Predisposing  factors  are:  Improper  prepara- 
tion of  bowel  and  stomach  for  operation,  by  failure  to  take  catharsis 
or  by  eating  too  near  the  time  for  operation;  manipulation  of  abdominal 
viscera,  especially  upper  intestinal  tract;  pyloric  or  intestinal  obstruc- 
tion. The  most  common  predisposing  cause  in  the  majority  of  cases 
is  the  ether  anesthesia. 

Prophylaxis  consists  in  minimizing  or  preventing  the  predisposing 
causes.  For  the  continued  nausea  and  vomiting  that  occurs  after 
the  first  twelve  hours  and  that  does  not  disappear  after  the  usual 
vomiting  following  anesthesia,  examine  the  patient  carefully  for 
signs  of  obstruction  and  dilatation  of  the  stomach.  Often  even 
without  obstruction  a  thorough  lavage  with  water  at  temperature  of 
120°  F.  will  cause  tonic  contraction  of  the  wall  of  stomach  with  cessa- 
tion of  symptoms.  Lavage  is  the  most  reliable  method  of  dealing 
with  continued  vomiting.  Dilute  hydrochloric  acid  or  dilute  iodine 
solution  ITU  to  oz.  |  of  water,  given  by  mouth,  sometimes  relieves  the 
nausea.  When  the  nausea  persists  for  two  or  three  days  without  signs 
of  obstruction  an  abrupt  change  from  liquid  diet  to  a  light  selected 
solid  diet  will  often  immediately  relieve  this  distressing  symptom. 


TREATMENT  OF  ABDOMINAL  DISTENTION  181 


TREATMENT  OF  ABDOMINAL  DISTENTION. 

The  treatment  of  so-called  "  gas  pains"  has  been  mentioned  in  general 
in  considering  the  treatment  of  the  discomfort  of  the  patient  follow- 
ing surgical  operation.  Gas  pains  probably  represent  the  beginning 
peristaltic  movement  of  the  intestines  following  the  temporary  cessa- 
tion (functionally  at  least) ,  due  to  the  exposure  and  trauma  necessitated 
by  abdominal  section.  Unpleasant  as  they  are  to  the  patient,  to  the 
surgeon  they  are  not  of  unfavorable  significance  because  their  presence 
usually  means  a  re-establishment  of  the  normal  motor  activity  of  the 
intestinal  tract  which  is  causing  pain  because  of  accumulated  gas 
throughout  the  tract. ' 

The  subject  of  abdominal  distention  will  be  considered  in  detail 
because  of  its  relative  frequency  and  the  seriousness  of  the  outcome  if 
not  recognized  early  and  properly  treated.  Under  this  head  can  be 
considered  the  treatment  of  three  types:  (1)  Mild  abdominal  disten- 
tion, (2)  severe  abdominal  distention,  (3)  the  abdominal  distention 
of  ileus  (a)  functional,  (b)  mechanical. 

Following  abdominal  operations,  undoubtedly  there  is  always  an 
accumulation  of  gas  in  the  gastrointestinal  tract  which  varies  in 
amount  over  the  normal,  within  wide  limits;  and  also,  as  mentioned 
before,  there  is  probably  an  almost  complete  cessation  of  intestinal 
muscular  activity  for  some  hours  following  operation.  When  for 
some  reason  the  intestinal  wall  does  not  regain  its  tonicity,  or  having 
regained  it,  fails  to  maintain  sufficient  peristaltic  force  to  adequately 
expel  the  accumulated  gas,  the  resulting  symptom-complex  is  known  as 
abdominal  distention. 

The  term  ileus  signifies  a  symptom-complex  resulting  from  the  arrest 
of  passage  of  intestinal  contents.  In  general,  prophylaxis  is  the  key- 
note of  the  treatment  of  abdominal  distention,  and  this  can  be  divided 
into:  (a)  Ante-operative  treatment,  (6)  treatment  during  operation, 
(c)  postoperative  treatment. 

(a)  Ante-operative  Prophylactic  Treatment. — A  thorough  cleaning  out 
of  the  gastro-intestinal  tract  is  essential  before  operation,  and  the 
cases  (as  for  instance,  the  emergency  cases),  in  which  there  has  not  been 
sufficient  time  to  do  this,  are  most  prone  to  postoperative  distention. 
On  the  other  hand,  too  severe  purging  before  operation  is  to  be  dis- 
couraged, as  it  may  defeat  its  purpose  and  produce  just  what  it  aims 
to  avoid. 

In  a  routine  case  upon  which  an  abdominal  operation  is  to  be 
performed  in  the  morning,  for  instance,  no  extensive  preparation  is 
necessary.  The  preparation  should  be  as  simple  as  possible.  On 
the  day  previous,  the  patient  may  enjoy  a  light  evening  meal,  and  that 
night  castor  oil  §  j-5  iss,  or  some  equally  efficacious  cathartic,  should 
be  given,  followed  by  a  requisite  number  of  soapsuds  enemata,  six 
hours  before  operation,  to  be  given  until  the  return  is  clear.     Usually 


182  TREATMENT  OF  POSTOPERATIVE  CONDITIONS 

two  will  suffice.     Water  by  mouth  should  be  encouraged  up  to  two 
hours  before  operation. 

(b)  Prophylactic  Treatment  During  Operation. — Abdominal  distention 
is  distinctly  less  frequent  and  severe  in  cases  in  which  gas  and  oxygen 
are  used  throughout  as  the  general  anesthetic  and  infiltration  with 
local  anesthesia  is  used  at  the  site  of  operation. 

The  most  important  prophylactic  measures,  however,  and  these 
cannot  be  too  strongly  emphasized,  are  gentleness  on  the  part  of  the 
surgeon  in  manipulation  of  the  intestines,  great  care  in  the  actual 
handling  of  viscera  and  in  placing  retractors,  and  a  minimum  amount 
of  exposure.  It  can  be  truly  said  that  postoperative  distention  varies 
in  direct  proportion  to  the  amount  of  trauma  to  which  the  viscera 
are  subjected  at  the  time  of  operation.  In  dealing  with  infective 
conditions  a  minimum  amount  of  trauma  is  even  more  important, 
because  of  the  direct  effect  of  infection  within  the  peritoneal  cavity 
upon  distention. 

(c)  Postoperative  Prophylaxis. — Because  of  the  possibility  of  disten- 
tion and  also  because  of  the  usual  depletion  of  the  patient  following 
an  abdominal  operation,  and  the  consequent  need  of  fluids,  an  excellent 
method  of  prophylaxis  to  be  employed  is  the  early  use  of  colon  irriga- 
tions as  a  routine  measure.  They  may  be  begun  eight  hours  after 
operation  and  can  be  repeated  every  eight  hours,  or  twice  a  day,  and 
can  be  alternated  with  salt  solution  per  rectum  to  be  retained  about 
4  to  6  oz.  every  eight  hours.  These  will  alleviate  thirst,  will  be  found 
to  be  stimulating  and  if  properly  given  will  cause  practically  no  dis- 
comfort. As  do  all  postoperative  measures,  however,  they  require 
care  in  the  giving,  and  only  too  often  is  the  entire  procedure  left  to  an 
untrained  attendant. 

A  method  which  has  proven  efficient  over  a  large  series  of  cases  and 
which  causes  the  patient,  under  ordinary  conditions,  no  discomfort 
whatever,  is  as  follows:  (1)  Ordinary  tap  water  is  used  at  a  maintained 
temperature  of  120°  F.,  (2)  the  rubber  tubing  should  consist  of:  (a) 
an  outlet  tube — one  large  rectal  tube  with  a  distal  opening  and  at 
least  three  large  lateral  fenestra?  (this  should  not  be  too  soft  but  very 
flexible),  (b)  an  inlet  tube — an  ordinary  medium-sized  catheter,  (c) 
sufficient  ordinary  rubber  tubing  to  connect  the  inlet  tube  with  the 
irrigating  can  and  the  outlet  tube  with  a  pail.  Glass  connecting  rods 
can  be  used  to  connect  the  various  segments  of  tubing. 

The  irrigating  can  is  brought  to  the  side  of  the  bed  at  about  8"-12" 
above  the  bed  level;  the  water  is  made  ready  and  both  very  hot  and 
cold  water  should  be  at  hand  to  regulate  the  temperature  of  the  irrigat- 
ing fluid,  as  indicated  by  a  thermometer.  The  water  from  the  irrigat- 
ing can  is  allowed  to  flow  through  the  tubing  until  it  is  well  heated 
and  the  air  is  expelled  by  the  column  of  water  which  completely  fills 
it.  Then  with  the  tip  of  the  inlet  tube  introduced  into  the  distal 
lateral  fenestra  of  the  outlet  tube,  and  both  well  lubricated,  they  are 
introduced  as  one  into  the  rectum,  the  patient  being  asked  to  "bear 


TREATMENT  OF  ABDOMINAL  DISTENTION  183 

down  as  if  straining  at  stool,"  while  the  tubes  are  passed  by  the 
sphincter. 

If  hemorrhoids  are  present  or  rectal  tenesmus  exists,  a  simple 
method  of  completely  lubricating  the  rectal  canal  is  to  introduce 
vaselin  into  the  rectum  by  means  of  a  fenestrated  hard-rubber  nozzle, 
into  which  the  lubricating  medium  is  gently  forced  by  a  screw  cap 
outside.  This  will  make  the  introduction  of  the  tubes  practically 
painless. 

The  outlet  tube  is  introduced  for  a  greater  distance  than  the  inlet, 
approximately  6  to  9  inches  for  the  outlet  tube,  and  3  to  4  inches  for  the 
inlet  tube,  and  the  water  is  allowed  to  run,  the  return  flow  passing  down 
into  a  good-sized  receptacle  on  the  floor.  A  colon  irrigation  must  be 
watched  all  the  time  by  the  person  in  charge.  If  the  outflow  ceases 
during  the  operation,  gentle  manipulation  of  the  outlet  tube  will 
usually  cause  it  to  begin  again  at  once;  if  not,  the  inlet  tube  is  pinched, 
shutting  off  the  inflow  until  by  manipulation  of  the  tubes  the  outflow 
is  resumed.  From  3  to  5  gallons  of  water  is  used  and  it  is  allowed  to 
flow  in  slowly,  the  entire  process  taking  from  forty-five  minutes  to  an 
hour. 

During  the  procedure  the  patient  remains  in  a  dorsal  position  with 
the  thighs  and  legs  comfortably  flexed,  and  if  properly  given  the  hot 
irrigating  fluid  readily  passes  around  to  the  ileocecal  junction,  thus 
reaching  the  entire  absorbing  surface  of  the  colon. 

A  colon  irrigation  is  considered  effective,  if  besides  the  intake  of 
water  which  the  patient  absorbs,  which  varies  from  a  pint  to  two 
pints,  fecal  material  and  flatus  are  expelled,  the  amount  of  the  latter 
being  estimated  by  observing  the  bubbles  of  gas  escaping  from  the  end 
of  the  outlet  tube,  which  ought  to  be  submerged  in  the  water  in  the 
receptacle  for  the  outflow. 

1 .  Active  Treatment  of  Mild  Abdominal  Distention. — Usually  moderate 
distention  as  evidenced  clinically  by  the  physical  signs  of  accumulation 
of  gas  in  the  gastro-intestinal  tract  and  some  abdominal  discomfort 
on  the  part  of  the  patient  on  the  first  and  second  day  following  opera- 
tion, is  but  temporary  and  responds  readily  to  treatment.  This  is 
not  alarming.  In  these  cases  frequently,  simply  the  introduction  of  a 
rectal  tube  is  sufficient  to  start  the  expulsion  of  flatus,  and  no  more 
difficulty  ensues.  Placing  the  patient  on  his  side  with  thighs  flexed 
frequently  assists  also  in  the  expulsion  of  gas.  These  failing,  a  soap- 
suds enema  can  be  given  with  good  results,  or  the  routine  colon  irriga- 
tions, usually  on  the  second  day,  stimulate  peristalsis  and  gas  is 
expelled. 

Later  on  during  convalescence  mild  distention  usually  can  be 
controlled  by  the  above  methods  in  addition  to  regulation  of  diet 
(especially  the  elimination  of  milk),  and  catharsis. 

2.  Treatment  of  Severe  Abdominal  Distention. — We  now  come  to  the 
consideration  of  cases  in  which  distention  is  present  and  apparently 
increasing,  and  the  patient  is  passing  but  a  small  amount  of  flatus 


184  TREATMENT  OF  POSTOPERATIVE  CONDITIONS 

per  rectum  on  the  third  or  fourth  day.  One  has  here  an  entirely 
different  problem  with  which  to  deal.  It  is  now  most  important  to 
get  results  and  quickly.  The  danger  is  a  very  real  one.  The  distention 
may  increase,  embarrassing  the  respiration  and  even  the  heart  action; 
tendency  to  kinking  of  the  distended  intestines  is  increased  and, 
finally,  it  may  terminate  fatally. 

One  should  be  able  to  determine  whether  the  distension  is  involving 
chiefly  the  small  intestine,  large  intestine  or  stomach  by  the  physical 
signs,  especially  percussion;  but  not  always  is  this  possible.  If  there 
is  any  suspicion  of  gastric  distention,  a  lavage  with  very  hot  tap  water 
(temperature  115°  to  120°  F.)  should  be  given  at  once  and  this  gives 
the  patient  the  benefit  of  the  doubt.  If  a  large  amount  of  flatus  and 
gastric  contents  are  found,  lavage  can  be  continued  until  practically 
no  more  gas  escapes  and  the  return  is  clear.  Too  frequently  this 
postoperative  complication  is  not  recognized  and  treated  in  this 
simple  way  until  the  patient  is  hiccoughing  or  even  vomiting,  or  until 
it  is  too  late.  Lavage  may  be  repeated  as  indicated  every  four  hours 
and  very  hot  water  is  strongly  recommended  for  its  stimulating  effect 
both  upon  the  gastric  wall  and  generally.  Sometimes  the  addition 
of  sodium  bicarbonate  is  of  advantage  in  the  water  and  at  times 
magnesium  sulphate  Bss-gj  may  be  introduced  through  the  tube 
and  allowed  to  remain  after  lavage  in  general  abdominal  distention,  in 
a  further  effort  to  stimulate  peristalsis. 

Medical  enemata  in  combination  with  hot  turpentine  stupes  are 
most  useful,  to  be  employed  in  addition  to  the  colon  irrigations  and 
lavage.  Of  drugs,  of  somewhat  doubtful  value,  eserin  gr.  ■£$  or 
pituitary  extract  1  c.c,  given  hypodermically,  may  prove  of  value,  and 
when  they  do,  are  very  efficacious.  The  most  efficient  enemata  for 
this  purpose  are  those  containing  turpentine,  ox-gall,  assafetida, 
glycerin  or  milk  and  molasses.     They  may  be  used  as  follows: 

Turpentine,  g  ij 

Olive  oil,  5  viij 

followed  in  one  hour  by  a  soapsuds  enema;  or, 

Fel  bo  vis,  gss 

Salt  solution,  Oj 

followed  in  one  hour  by  a  soapsuds  enema;  or, 

Fel  bovis,  gj 

Turpentine,  gij 

Soapsuds,  Oj 


or, 


Assafetida,  giij 

Soapsuds,  q.  s.  ad     Oj 


Any  one  of  the  above  enemata  can  be  given  together  with  the  stuping. 
As  in  giving  colon  irrigations,  so  in  applying  turpentine  stupes,  the 
result  depends  to  a  very  large  degree  upon  the  manner  in  which  they 
are  administered. 


TREATMENT  OF  ABDOMINAL  DISTENTION  185 

Turpentine  stupes  to  be  efficient  should  be  administered  as  follows: 
Flannel  squares  are  used  and  these  are  large  enough  to  extend  over  the 
entire  abdomen  and  chest  wall  from  the  mammary  line  to  the  pubis 
and  well  down  on  the  flanks.  There  should  be  at  least  six  thicknesses 
of  flannel.  The  abdominal  binder  and  cotton  if  present  are  removed, 
leaving  only  a  single  dressing  over  the  wound.  All  of  the  exposed 
skin  of  the  abdomen  and  chest  should  be  well  greased  with  vaselin 
to  prevent  burning  of  the  skin  by  the  hot  stupes.  The  stupes  are  made 
by  first  soaking  and  then  wringing  t>ut  by  means  of  wringing  rods  the 
squares  of  flannel  in  very  hot  water  to  which  turpentine  about  §  iv 
to  the  quart  has  been  added.  This  should  be  done  at  the  bedside 
and  the  stupes  applied  immediately,  changed  every  ten  minutes  and 
applied  for  one-half  hour  every  two  hours  until  results  are  obtained. 

3.  Abdominal  Distention  due  to  Paralytic  Ileus. — This  represents  the 
very  grave  type  in  which  there  is  an  arrest  of  the  passage  of  intestinal 
contents,  following  operation.  It  is  usually  associated  with  sepsis  and 
especially  spreading  peritonitis,  although  it  may  simply  represent  a 
further  stage  of  the  severe  type  of  distention. 

Catharsis,  although  employed  by  some  surgeons,  has  not  met  with 
success  in  our  hands  in  this  type  of  case.  In  the  milder  types  of  post- 
operative distention  and  before  the  paralytic  stage  has  been  reached 
it  is  of  real  value. 

In  the  type  under  consideration,  frequent  and  repeated  washings  of 
the  gastro-intestinal  tract  from  above  and  below,  drastic  enemata 
and  turpentine  stupes  are  by  far  the  most  efficient  methods  of  treat- 
ment. Eserin  and  pituitary  extract,  hypodermically,  are  also  used 
in  repeated  dosage  and  strychnin  in  large  doses  is  advised  by  many 
surgeons.  Placing  the  patient  in  a  semisitting  posture  may  also  be 
of  some  benefit.  The  efficacy  both  of  the  lavage  and  colon  irrigations 
is  greatly  increased  by  using  water  as  hot  as  the  patient  can  comfort- 
ably bear. 

The  indication  is  to  re-establish  normal  peristaltic  movement  as 
evidenced  clinically  by  the  spontaneous  expulsion  of  flatus;  with  this 
object  in  view  there  should  be  no  cessation  in  the  treatment,  except 
for  short  periods  of  rest  for  the  patient,  until  this  has  been  accom- 
plished. In  the  meantime,  the  patient  should  be  given  nothing  by 
mouth,  some  simple  wash  being  used  to  keep  the  mouth  moist. 
Not  until  all  vomiting  has  ceased  and  flatus  has  been  expelled  should 
the  intake  of  fluids  be  resumed.  The  simplest  fluid,  as  albumen 
water  with  orange  juice  §  j-§ij  every  two  hours,  should  be  given,  and 
when  albumen  water  and  broth  have  been  successfully  taken,  more  of 
the  ordinary  fluids  and  in  larger  amounts  can  be  easily  digested. 

When  depletion  of  bodily  fluids  exists,  as  in  septic  cases,  hypo- 
dermoclysis  can  be  given.  Proctoclysis  or  the  Murphy  drip  method  is 
frequently  very  satisfactory  and  the  amount  of  fluid  absorbed  some- 
times is  astonishing,  as  much  as  a  pint  an  hour  being  absorbed  usually 
without  any  difficulty  until  the  normal  balance  is  re-established.    This 


L86  TREATMENT  OF  POSTOPERATIVE  CONDITIONS 

can  be -arranged  by  using  a  small  irrigating  ean,  4  to  ">  inches  above 
the  bed  level,  the  water  in  which  can  be  kept  hot  by  means  of  a  small 
electric  heater,  a  short  connecting  tube  uniting  the  irrigating  can  with 
a  double-bulbed  rectal  nozzle  (Fig.  85)  or  good-sized  rectal  tube  with 
lateral  fenestra,  which  is  inserted  from  3  to  5  inches  into  the  rectum. 
The  fluid  will  wash  back  and  forth,  thus  allowing  gas  and  fecal  matter 
to  escape  as  the  fluid  is  absorbed.  This  method  of  proctoclysis  is 
valuable  in  any  of  the  postoperative  conditions  in  which  there  is  an 
indication  for  giving  fluids  and  stimulating  peristalsis. 

Because  of  the  possibility  of  obstruction,  cases  of  persistent  post- 
operative distention  which  seem  to  be  getting  worse,  despite  vigorous 
treatment  as  indicated  over  a  reasonable  length  of  time,  are  to  be  oper- 
ated upon.  This  is  generally  best  accomplished  by  means  of  a  median 
incision,  and  in  the  event  of  finding  no  definite  obstruction,  such  as 
angulation  or  an  adhesive  band,  a  low  enterostomy  may  be  of  value — 
A  Paul  tube  is  inserted  and  the  intestine,  after  the  escape  of  gas  in 
the  immediate  vicinity  of  the  opening,  can  be  irrigated  with  very 
hot  saline  solution  or  water,  and  this  may  later  be  frequently  repeated. 


Fig.  85. — Electa!  nozzle  for  Murphy  drip. 

Distention  Following  Mechanical  Ileus. — Postoperative  intestinal 
obstruction  may  occur  early,  immediately  following  operation,  or 
late,  due  to  connective-tissue  adhesions. 

It  is  only  the  early  type  which  we  shall  now  consider.  Frequently 
the  cause  is  a  kinking  of  the  intestines  when  put  back  into  the  peritoneal 
cavity  at  operation.  In  cases  of  peritonitis  especially  is  this  true,  as 
the  intestine  is  already  paralyzed;  in  other  cases  the  kinking  takes  place 
in  an  overdistended  intestine,  as  found  in  paralytic  ileus.  Drainage 
tubes  may  also  cause  mechanical  obstruction. 

The  diagnosis  of  this  condition  is  very  difficult,  and  especially  is  the 
differential  diagnosis  between  this  and  paralytic  ileus  made  difficult 
by  the  very  nature  of  the  cases  in  which  they  most  frequently  occur, 
and  the  presence  of  infection.  The  symptoms  are  frequently  the  same 
as  in  paralytic  ileus  and  there  is  ordinarily  no  sudden  pain. 

The  symptoms  may  appear  from  two  to  ten  days  after  the  operation, 
and  they  may  appear  suddenly  as  acute  colicky  pains  followed  by 
increasing  distention,  which  at  first,  however,  may  be  localized; 
failure  to  pass  flatus  and  vomiting  indicating  a  sudden  obstruction 
with  interference  of  the  blood  supply.  On  the  other  hand  when 
secondary  to  a  pre-existing  paralytic  ileus,  as  is  frequently  the  case, 


THROMBOSIS  AXD  EMBOLISM  Is, 

the  symptoms  as  mentioned  are  frequently  the  same  as  in  the  former, 
and  appear  gradually,  there  being  no  sudden  sharp  pain  but  simply  an 
increasing  distention,  failure  to  pass  gas,  vomiting  and  finally  shock. 

The  treatment,  therefore,  in  any  ease  of  postoperative  distention 
should  be  all  the  more  thoroughly  carried  out  because  it  may  prevent 
the  actual  occurrence  of  later  obstruction. 

If  all  the  palliative  means  suggested  under  paralytic  ileus  have  been 
employed  and  have  failed,  operation  is  indicated  to  remove  the  cause 
of  obstruction.  When  to  operate,  however,  in  a  given  case  is  indeed 
a  very  difficult  question  to  decide,  and  the  difficulty  of  diagnosis 
makes  it  more  so.  In  any  form  of  severe,  persistent  postoperative 
distention,  certainly  delay  is  more  dangerous  than  operation.  If  a 
mechanical  cause  is  suspected  and  the  patient  is  in  fair  condition,  a 
median  incision  can  be  used,  through  which  a  quick  and  thorough 
exploration  can  be  made  and  the  cause  of  the  obstruction  removed  if 
found,  and  if  not  found  a  low  enterostomy  can  be  performed  and  a  Paul 
tube  used,  as  previously  mentioned.  If  the  patient's  condition  does 
not  warrant  this,  as  a  last  resort,  an  enterostomy  can  be  made  with 
local  anesthesia. 

THROMBOSIS  AND  EMBOLISM. 

Thrombophlebitis  is  one  of  the  postoperative  complications  which, 
although  not  occurring  frequently,  when  it  does  appear  causes  much 
discomfort  to  the  patient,  is  not  easily  amenable  to  treatment,  and  may 
be  associated  with  embolism. 

In  a  recent  series  of  6S25  cases  operated  upon  at  the  Mayo  Clinic, 
thrombophlebitis  of  the  internal  or  external  saphenous  veins  occurred 
in  14.  Infection,  as  far  as  the  type  of  the  case  is  concerned,  seems  to 
play  no  part  in  the  occurrence  of  this  complication,  as  it  occurs  in  the 
so-called  clean  cases  as  frequently  as  in  the  infected. 

It  usually  occurs  in  the  second  or  third  week  after  operation,  involves 
the  saphenous  and  femoral  veins  chiefly,  is  more  common  on  the  left 
side  and  most  frequently  follows  operations  in  the  pelvis  or  lower 
abdomen  and  especially  in  anemic  patients. 

The  treatment  consists  in  prophylaxis  and  active  treatment.  The 
prophylaxis  consists  in  the  usual  care  in  subjecting  the  patient  to  the 
minimum  amount  of  trauma  at  operation,  especial  care  being  taken  to 
carefully  ligate  bloodvessels  rather  than  traumatize  them  directly  or 
by  retractors. 

The  active  treatment  consists,  in  brief,  of  absolute  rest  in  bed  for 
from  three  to  six  weeks,  local  application  of  heat  or  cold  to  the  part 
and  elevation  of  the  affected  limb  on  a  soft  pillow  where  it  can  be 
protected.  Ichthyol  locally  by  some  surgeons  is  considered  of  value. 
Massage  of  any  sort  is  to  be  avoided. 

Pulmonary  Embolism. — The  time  for  sitting  up,  getting  out  of  bed 
and  walking  around  seems  to  bear  no  important  relation  to  this  con- 


188  TREATMENT  OF  POSTOPERATIVE  CONDITIONS 

dition.  It  is  one  of  the  most  distressing  of  the  surgical  accidents  which 
may  happen  during  convalescence  and  usually  happens  when  least 
expected. 

In  cases  in  which  blocking  of  one  of  the  main  branches  of  the  pul- 
monary artery  has  taken  place,  practically  no  opportunity  is  afforded 
for  treatment.  If,  however,  the  patient  survives  the  initial  shock, 
a  large  dose  of  morphine  should  be  given  immediately,  absolute  quiet 
maintained,  heat  applied  to  the  extremities  and  cardiac  and  respira- 
tory stimulants  given  as  indicated.  Atrophine  sulphate  gr.  ^  hypo- 
dermatically  is  a  good  respiratory  stimulant,  while  for  cardiac  distress 
strophanthine  gr.  y^  or  digitalin  gr.  T\^  intravenously  and  camphor 
gr.  j  in  oil  Mix  are  among  the  most  valuable.  Recovery,  however, 
depends  upon  the  situation  and  size  of  the  embolus. 


CHAPTER  X. 

INJURIES  AND  DISEASES  OF  THE  SKIN  AND 
SUBCUTANEOUS  TISSUES. 

INJURIES  OF  THE  SKIN. 

Burns  and  Scalds. — Burns  and  scalds  are  injuries  due  to  the  effects 
of  heat.  Burns  are  caused  by  contact  with  a  flame  or  some  hot  solid 
substance,  by  exposure  to  the  rays  of  the  sun  or  the  a-rays,  by  contact 
with  a  strong  electric  current,  or  simply  by  heat  radiated  from  flame 
or  some  hot  object.  Scalds  are  produced  by  contact  with  steam  or 
some  boiling  or  heated  liquid.  The  nature  of  the  two  injuries  is 
identical,  although  their  lesions  may  differ  somewhat  in  appearance. 
The  effect  of  the  irritation  is  to  produce  a  reactionary  congestion, 
superficial  dermatitis,  or  more  or  less  extensive  necrosis  of  tissue. 
Dupuytren's  classification  of  burns  into  six  degrees  has  been  generally 
adopted:  first  degree,  characterized  by  simple  hyperemia  of  the  skin; 
second,  dermatitis  with  vesicles  or  bullae;  third,  necrosis  of  the  super- 
ficial layer  of  the  skin;  fourth,  complete  necrosis  of  the  skin;  fifth, 
necrosis  of  the  skin,  subcutaneous  tissue,  and  muscle;  sixth,  complete 
"carbonization"  of  an  extremity. 

Symptoms. — The  symptoms  of  burns  and  scalds  depend  upon  the 
location  and  extent  of  the  injury  and  the  character  of  the  burning  agent. 
They  may  be  divided  into  local  and  constitutional. 

The  local  symptoms  of  a  burn  are  a  sense  of  heat,  smarting,  and 
general  discomfort,  more  or  less  pain,  tenderness,  and  inability  to 
use  the  part.  In  addition  there  are  redness  and  swelling  of  the  skin, 
blisters  or  sloughing.  In  the  severer  forms  the  skin  may  be  blackened 
and  leathery.  In  scalds  the  skin  is  whitened,  thrown  into  ruga?,  and 
often  the  epidermis  is  detached  (Fig.  8G). 

The  constitutional  symptoms  of  burns  are  relatively  wholly  out  of 
proportion  to  the  apparent  injury,  and  are  relatively  greater  in  children 
and  in  cases  in  which  the  trunk  is  largely  involved.  Shock  is  present 
in  nearly  all  burns,  and  is  dependent  more  upon  the  location  and  extent 
of  the  burned  area  than  the  depth  of  the  injury.  It  is  generally  fatal 
if  an  area  equal  to  one-third  of  the  surface  of  the  body  is  involved, 
and  in  cases  in  which  much  less  of  the  surface  is  injured  in  children, 
especially  if  the  burn  occurs  on  the  chest  or  abdomen.  Elevation 
of  temperature  and  other  symptoms  of  grave  toxemia  are  present 
in  severe  burns  accompanied  by  extensive  necrosis.  This  in  the  early 
stage  is  probably  due  to  absorption  of  toxic  substances  from  the  burned 
tissues;  later,  to  sepsis.     Headache,  restlessness,  delirium,  and  coma 


190  INJURIES  AND  DISEASES  OF   THE  SKIN 

may  follow  a  burn,  due  to  meningeal  congestion  and  exudate,  and  in 
certain  rare  cases  a  duodenal  ulcer  will  develop,  evidenced  by  local 
pain,  hemorrhage  from  the  stomach  or  bowels,  and  in  case  of  perfora- 
tion by  the  sudden  appearance  of  severe  epigastric  pain  accompanied 
by  evidences  of  local  peritonitis  and  progressively  increasing  shock. 
A  more  or  less  acute  nephritis  is  frequently  associated  with  an  extensive 
burn,  and  may  cause  death  from  suppression  of  urine  or  more  slowly 
developing  uremic  symptoms.  When  the  patient  has  been  exposed 
to  flame,  steam,  or  hot  vapors,  edema  of  the  glottis  may  occur,  with 
severe  bronchitis  and  pneumonia.  Retention  of  urine  occasionally 
results  from  edema  of  the  prepuce  or  swelling  of  the  glans. 

Treatment. — The  treatment  of  burns  of  limited  extent  and  of  moder- 
ate severity  consists  in  rest  and  the  application  of  a  dressing  of  a 
saturated  solution  of  sodium  bicarbonate,  carbolic  acid  (1  to  100), 
normal  salt  solution,  or  the  use  of  some  emollient  ointment,  as  zinc 


Fig.  86.— Scald  of  the  hand. 

oxide  or  boric  acid.  Where  blebs  form,  their  entire  dome  should  be 
trimmed  away  with  scissors  and  their  contents  removed  to  prevent 
its  becoming  infected.  Not  infrequently  patients  present  themselves 
for  treatment  after  extensive  burns  have  been  dressed  with  dry  gauze, 
which  has  become  firmly  adherent  to  the  entire  burnt  area.  Rather 
than  attempt  the  immediate  removal  of  the  dressing,  which  would 
in  all  probability  be  attended  with  some  bleeding  and  great  discomfort 
to  the  patient,  it  is  better  to  saturate  the  adherent  gauze  dressings 
with  a  bland  oil  such  as  albolene,  then  cover  it  with  rubber  tissue  to 
prevent  evaporation  and  wait  for  twenty-four  hours,  at  which  time 
the  dressing  should  be  easily  and  painlessly  removed.  In  the  severer 
forms,  especially  when  the  papillary  layer  of  the  skin  is  exposed,  the 
burned  surface  should  be  immediately  protected  from  the  air  and 
dressed  as  infrequently  as  possible.  The  pain  should  be  controlled 
by  small  doses  of  codeine  or  morphine,  although  it  must  be  remembered 
that  in  the  severest  cases,  accompanied  by  grave  toxemia,  morphine 


INJURIES  OF   THE  SKIS 


101 


tends  to  retard  elimination,  and  should  be  used  sparingly.  Fainting 
the  granulating  surface  of  a  painful  burn  with  a  2  per  cent,  solution 
of  silver  nitrate  will  often  give  marked  relief.  In  severe  burns  accom- 
panied by  necrosis  of  tissue,  if  possible  the  parts  should  be  disinfected 
and  dressed  antiseptically.  The  plan  of  treating  extensive  burns 
without  any  dressing  has  of  late  been  extensively  employed.  The 
patient  is  placed  in  a  bed  so  arranged  that  the  body  is  covered  by  a 
hood  made  of  a  blanket  or  piece  of  canvas,  the  head  being  outside 
(Fig.  87).  The  space  beneath  the  hood  is  heated  to  about  100°  F. 
by  means  of  a  hot-air  generator  or  electric  heater;  or  the  patient 
simply  lies  in  an  ordinary  bed  without  coverings,  in  a  room  in  which 
the  temperature  is  raised  to  100°  F.  or  above.  As  a  result  of  this 
treatment  the  burnecl  area  is  soon  covered  by  a  thick  dry  crust  which 


Fig.  87. 


-Dry  warm-air  treatment  of  burns.     Electric  heater  under  crib  with  warm-air 
pipe  on  each  side. 


excludes  the  air,  gives  great  comfort,  and  allows  the  healing  process 
when  aseptic  to  advance  as  under  any  other  protective  dressing.  In 
extensive  burns,  where  the  crust  formation  is  slow,  it  may  be  favored 
by  the  use  of  an  electric  fan,  which  promotes  rapid  drying  of  the 
moist  surfaces.  In  favorable  cases  cicatrization  takes  place  beneath 
the  crusts.  Where  much  infection  is  present,  or  when  the  resistance 
of  the  individual  is  reduced,  suppuration  occurs  beneath  the  scabs, 
and  may  give  rise  to  marked  systemic  reaction.  Occasionally  this 
may  be  reduced  by  removing  a  portion  of  the  scab  to  allow  drainage, 
but  generally  it  is  better  to  remove  the  crust  by  a  warm  bath  in  a 
solution  of  soda  bicarbonate  at  a  temperature  of  96°  and  allow  another 
to  form,  or  treat  the  ulcer  by  a  wet  aseptic  dressing  or  some  antiseptic- 
powder. 


192  INJURIES  AND  DISEASES  OF  THE  SKIN 

Shock  should  be  treated  by  stimulants  and  food,  meningeal  irritation 
by  sedatives  and  ice  to  the  head,  visceral  congestion  by  a  cold-water 
coil.  An  effort  should  always  be  made  to  promote  elimination  of  the 
toxins  by  cathartics  and  diuretics;  and  if  sepsis  follows,  supporting 
measures  should  be  faithfully  employed. 

The  healing  of  large  granulating  surfaces  may  be  hastened  by 
strapping  or  skin-grafting. 


Fig.  88. — Subcutaneous  hematoma  of  the  thigh. 

Contusions. — These  are  cutaneous  and  subcutaneous  injuries  caused 
by  blows  or  crushes,  and  are  associated  with  rupture  of  one  or  more 
small  vessels  in  the  skin  or  cellular  tissue.  The  hemorrhage  thus 
produced  may  be  slight,  giving  rise  to  a  dark  bluish  discoloration 
of  the  skin;  or  it  may  be  greater  in  extent,  and  form  a  large  collection 
or  hematoma  (Fig.  88).  Contusions  often  are  associated  with  wounds 
of  the  skin  and  other  injuries  of  the  soft  parts. 


DISEASES  OF  THE  SKIN 


I'.k; 


Treatment. — The  treatment  of  contusions,  when  any  is  necessary, 
should  consist  in  rest  for  the  part  and  the  application  of  heat  or  cold 
by  means  of  fomentations  or  wet  dressings  of  aluminum  acetate. 
If  uninfected,  and  not  increasing  in  size,  hematomata  should  not 
be  opened;  the  fluid,  however,  may  be  withdrawn  by  aspiration.  If 
infection  occurs,  a  free  incision  should  be  made,  the  cavity  emptied 
of  clots,  thoroughly  disinfected,  and  closed  with  sutures  and  drainage, 
or  packed  and  allowed  to  heal  by  granulation. 

DISEASES  OF  THE  SKIN. 

Dermatitis. — The  various  forms  of  simple  dermatitis  are  described 
in  text-books  on  Dermatology. 

Erysipelas  is  described  in  Chapter  III. 


'•■  -j*,         \< 

*  (  M  1111191  ' 

i&j&i          '-•■ 

Fig.  89. — X-ray  dermatitis  of  the  hands. 


X-ray  Dermatitis. — Exposure  to  the  Rontgen  rays  produces  a 
variety  of  skin  lesions.  A  single  long  exposure  may  give  rise  to  an 
area  of  hyperemia  which  is  tender  to  the  touch,  and  often  the  seat  of 
some  spontaneous  pain,  the  so-called  x-ray  burn.  More  prolonged 
exposure  to  the  rays  or  repeated  exposures  may  give  rise  to  chronic 
hyperemia,  dryness  of  the  skin  from  atrophy  of  the  sweat  gland, 
deformed  and  brittle  nails,  keratoses,  papillomata,  and  superficial 
and  deep  ulcerations.  These  lesions  are  all  exceedingly  chronic,  and 
any  ulcerative  process  is  apt  to  be  associated  with  severe  pain  (Fig.  89). 

Porter  and  White  have  recently  reported  the  histories  of  eleven 
cases  where  x-i&y  ulcerations  have  undergone  epitheliomatous  change. 
13 


194  IXJURIES  AND  DISEASES  OF   THE  SKIN 

All  of  these  occurred  in  .r-ray  operators,  and  in  many  cases  the  disease 
began  before  the  general  use  of  protective  agents.  In  one  case  illus- 
trated in  their  report,  ten  different  epitheliomatous  tumors  developed 
in  a  period  of  five  years,  requiring  twenty-five  operations  under  ether. 

Treatment. — The  treatment  of  the  milder  cases  of  x-ray  dermatitis 
consists  in  soothing  applications  and  the  avoidance  of  all  sources 
of  irritation.  Vaselin,  cold  cream,  orthoform,  and  a  wet  dressing 
of  aluminum  acetate  will  be  found  useful.  For  the  ulcerative  lesions 
which  resist  palliative  treatment,  excision  with  skin-grafting  consti- 
tutes the  best  treatment.  For  ulcerations  which  show  beginning 
malignant  change,  without  evidence  of  lymph-node  metastasis,  radium 
therapy  is  of  value;  in  more  advanced  disease  w'de  excision  or  ampu- 
tation i>  to  be  recommended. 

Furuncle,  or  Boil. — Furuncle  is  a  localized  inflammation  of  the  skin 
around  a  hair  follicle  or  the  duct  of  a  sebaceous  gland,  due  to  an  infec- 
tion, generally  by  Staphylococcus  pyogenes  aureus  or  albus.  The 
tissues  in  the  immediate  neighborhood  of  the  follicle  or  duct  become 
necrosed  and  surrounded  by  an  area  of  congestion  and  inflammatory 
exudate.  If  undisturbed,  the  necrotic  mass  gradually  softens  and 
forms  a  small  cavity  filled  with  pus,  which  eventually  ruptures  through 
the  epidermis,  discharges,  and  heals.  Boils  are  apt  to  appear  in 
crops  and  often  in  apparently  healthy  individuals,  due  to  infection 
being  carried  from  one  part  to  another  by  fingers  or  articles  of  clothing. 

Symptoms. — The  symptoms  of  a  bob1  are  first  a  localized  point  of 
tenderness,  which  is  soon  followed  by  a  small  reddened  conical  area  of 
induration,  on  the  apex  of  which  a  small  vesicle  is  often  seen.  There 
is  usually  considerable  pain  of  a  throbbing  character,  with  marked 
tenderness  and  muscular  rigidity  in  the  region.  Furuncles  may  occur 
anywhere,  but  are  seen  more  frequently  on  the  neck,  face,  buttocks. 
arms,  and  in  the  axilhe. 

Treatment. — The  treatment  should  be  to  promote  early  softening  of 
the  necrosed  mass  and  evacuation  of  the  pus.  This  is  accomplished 
best  by  a  wet  dressing  of  mercuric  chloride  (1  to  5000)  or  a  flaxseed 
poultice,  with  incision  as  soon  as  softening  is  detected.  While  most 
modern  surgical  authorities  condemn  the  use  of  poultices  on  the 
ground  that  they  favor  the  spread  of  infection  by  allowing  the  pus 
from  a  discharging  furuncle  to  infect  surrounding  healthy  follicles, 
there  is  no  objection  to  their  employment  before  the  focus  is  opened, 
at  which  time  they  often  relieve  pain,  favor  early  softening,  and  con- 
tribute to  the  comfort  of  the  patient. 

The  use  of  Bier's  hyperemic  cups  after  a  comparatively  small 
incision  will  hasten  resolution  in  many  cases  and  avoid  conspicuous 
cicatrices.  Early  incision  through  the  necrosed  area,  followed  by 
a  wet  bichloride  dressing,  will  often  save  time  by  aborting  the  process. 
Removal  of  the  offending  hair  when  present  and  applying  pure  carbolic 
acid  to  its  follicle  by  means  of  a  pointed  match  or  toothpick  is  recom- 
mended in  the  early  stages.     To  prevent  a  succession  of  boils,  the  sur- 


DISEASES  OF  THE  SKIN  195 

rounding  parts  should  be  washed  frequently  with  soap  and  water, 
afterward  bathed  with  a  solution  of  bichloride  ( 1  to  1000),  and  protected 
by  a  dressing  of  sterile  gauze.  The  use  of  autogenous  vaccines  in 
cases  which  have  repeated  recurrences  is  often  of  considerable  value. 
Care  should  be  taken  to  disinfect  the  fingers  after  dressing  or  handling 
the  infected  region.  Furuncles  in  the  early  stage  often  may  be  aborted 
by  the  application  of  an  ointment  or  plaster  of  salicylic  acid.  Klotz's 
formula  is  the  following: 

Empl.  plumbi,  60  0 

Empl.  saponis,  25  0 

Petrol;. ti.  8  0 

Cerat.  jap.,  2  0 

Ac.  salicylici,  *                                                                          o  0 — M. 

Cellulitis. — Cellulitis  is  an  inflammation  of  the  cellular  tissue.  All 
tissues  are  cellular,  but  what  is  meant  by  the  term  "cellular  tissue" 
in  general  are  those  tissues  made  up  of  the  more  non-specialized  con- 
nective-tissue cells  that  are  the  framework  supporting  more  highly 
specialized  cells,  and  the  agencies  through  which  they  obtain  their 
nutrition.  For  instance,  subcutaneous  tissue,  fascial  planes,  and  the 
interstitial  substance  of  organs  are  examples  of  cellular  tissues.  Theo- 
retically, it  is  difficult  to  conceive  of  a  pure  cellulitis  without  involve- 
ment of  other  more  specialized  tissues.  Clinically,  however,  the  term 
is  widely  used — most  frequently  in  describing  inflammatory  processes 
in  the  subcutaneous  tissues  or  intermuscular  fascial  planes,  as  in  a 
deep  cellulitis  of  the  neck  or  Ludwig's  angina,  in  the  tissues  of  the 
orbit,  in  the  perineal  fascial  planes,  or  in  the  tissues  outside  the 
peritoneum,  etc. 

The  intensity  and  extent  of  a  cellulitis  varies  considerably  with  the 
nature  of  the  infecting  agent,  the  susceptibility  of  the  individual  and 
the  structure  and  vascularity  of  the  part  affected.  In  general,  strep- 
tococci, a  virulent  strain  of  colon  bacilli  or  staphylococci,  or  an  organ- 
ism such  as  the  Bacillus  aerogenes  capsulatus,  or  even  an  extravasation 
of  normal  urine  may  cause  an  exceedingly  rapid  progressing  cellulitis, 
but  the  usual  type  of  staphylococcus  aureus  or  albus,  which  is  by 
far  the  commonest  infective  agent,  may  cause  a  distinctly  localized 
and  gradually  spreading  cellulitis  with  termination  in  abscess  for- 
mation. Cellulitis  in  a  diabetic,  in  an  individual  with  spinal  cord 
lesion,  or  in  an  arteriosclerotic  alcoholic,  may  be  rapidly  fatal.  A 
cellulitis  where  the  tissues  are  loose  and  vascular,  such  as  the  back 
of  the  hand,  scrotum,  lip  or  eyelid,  is  generally  very  rapid  in  its 
course,  but  in  the  palm  of  the  hand  or  in  the  tissues  of  the  back  it 
becomes  localized  more  readily. 

In  a  general  way  the  causes,  symptoms  and  treatment  of  cellulitis 
may  be  indicated  as  follows: 

Causes. — First,  trauma — such  as  friction,  heat,  frost,  counter-irritants, 
injections  of  irritating  drugs  or  sera,  snake  or  insect  bites,  etc. 


196 


INJURIES  AND  DISEASES  OF  THE  SKIN 


Second,  infection — through  wounds,  by  extension  from  already 
existing  infections,  by  transmission  through  blood  or  lymph  stream,  etc. 

Third,  metabolic  disturbances,  such  as  gout. 

Symptoms. — Tense,  throbbing  pain,  increased  by  motion;  impair- 
ment or  loss  of  function,  tenderness,  redness,  heat,  swelling,  tenderness 
and  enlargement  of  associated  lymph  nodes,  leukocytosis  and  the 
general  systemic  symptoms  of  fever. 

Treatment. — Rest,  local  (splint),  rest  in  bed,  sedatives  if  necessary, 
copious  water  drinking,  catharsis,  moist  heat,  poultices,  wet  dressings, 
etc.,  intermittently;  external  medication,  ichthyol  or  mercurial  oint- 
ment, aluminum  acetate  solutions,  etc. 


,f££!iigjggg^gN 


Fiu.  90. — Diagram  showing  the  layers  and  structure; 
subcutaneous  tissue. 


)f  the  skin  and 


Operative  Treatment. — The  question  as  to  when  and  how  to  operate 
on  cellulitis  cases  is  important.  It  is  exceedingly  difficult  to  tell 
whether  a  cellulitis  is  going  to  break  down  and  form  an  abscess  or  not. 
Where  the  process  is  diffuse  and  there  is  no  definite  point  of  extreme 
tenderness  or  sign  of  fluctuation,  and  where  the  patient's  general 
condition  is  not  serious,  it  is  far  better  to  treat  conservatively.  In 
most  cases  after  twenty-four  or  forty-eight  hours,  the  diffused  process 
is  either  subsiding  or  a  definite  area  of  abscess  formation  can  be  made 
out.  During  this  time  it  is  often  useful,  besides  putting  the  patient 
to  bed  and  administering  a  cathartic,  to  immobilize  the  part  as  much  as 
possible  and  every  two  hours  apply  moist  heat  directly  through  the 


DISEASES  OF  THE  SKIN 


197 


dressing  for  half  an  hour  at  a  time.  It  is  questionable  of  how  much 
value  various  types  of  dressing  are;  20  per  cent,  ichthyol  ointment,  10 
per  cent,  blue  ointment  or  aluminum  acetate  dressings,  or  even  plain 
salt  solution  dressings  are  serviceable.  In  certain  cases  of  cellulitis 
the  infiltration  involves  important  structures,  as  in  the  deep  cellulitis 


Fig.  91. — Diagrammatic  drawing  of  a  subcutaneous  abscess  at  an  early  stage  where  the 
dividing  line  between  living  and  necrotic  tissue  has  not  yet  been  established. 

of  the  neck.  The  patient  may  be  extremely  sick  and  operation  may  be 
indicated.  In  such  circumstances  the  incision  must  be  free  enough 
to  allow  of  the  exposure  of  enough  of  the  affected  area  to  overcome  the 
danger  of  the  absorption  incidental  to  the  effect  of  any  operation. 
Where  the  process  has  localized  the  abscess  should  be  treated  as  under 
ordinarv  circumstances. 


Fig.  92. — Diagram  of  a  subcutaneous  abscess  after  incision,  where  the  dividing 
line  between  living  and  necrotic  tissue  has  been  established,  except  where  the  dense 
trabeculse  of  the  subcutaneous  tissue  are  still  attached  to  the  slough  or  "core"  of  the 
boil.  It  is  through  the  action  of  the  living  cells  (e.  g.,  phagocytes)  in  the  granulating 
wall  of  the  abscess  that  complete  solution  of  these  trabeculse  takes  place  and  "sequestra- 
tion" becomes  complete.  A,  necrotic  tissue  slough;  B,  dense  subcutaneous  tissue 
trabecules  surrounded  by  living  cells;    C,  granulating  wall  of  abscess. 


Subcutaneous  Abscess  (Figs.  91  and  92). — In  dealing  with  a  sub- 
cutaneous abscess,  it  is  important  to  remember  that  the  corium  as  well  as 
the  epidermis  must  be  penetrated  before  adequate  drainage  of  the  abscess 
cavity  itself  can  be  effected.  There  is  a  wide  variation  in  the  density 
and  thickness  of  the  corium  in  different  parts  of  the  body.  An  insufficient 


198 


INJURIES  AND  DISEASES  OF   THE  SKIN 


opening  through  this  layer  is  a  frequent  factor  in  the  failure  to  establish 
adequate  drainage.  In  many  such  abscesses  sufficient  drainage  can 
be  established  by  using  pure  carbolic  acid  to  enlarge  an  already  existing 
small  sinus.  Its  action  is  such  as  to  shrivel  up  and  anesthetize  the 
tissues.  By  carefully  applying  with  a  pointed  toothpick  the  diameter 
of  the  sinus  can  be  considerably  enlarged.  Sometimes  a  very  minute 
strip  of  tape  or  even  soft  white  cotton  twine  soaked  in  pure  carbolic 
may  be  left  in  the  sinus  as  a  drain.  Care  must  be  taken  to  prevent 
dry  crusting  of  the  exudate  in  the  dressing  of  a  recently  opened  abscess. 
This  is  best  done  by  the  use  of  either  ointment  or  wet  dressings  or  by 


w^w0$$m       mm    W 


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MMi: 


^»: 


:& 


•'..& 


-c 


— D 


Fig.  93.- — Diagrammatic  drawing  of  a  carbuncle.  ^4,  cribriform  holes  in  the  epidermis; 
B,  area  of  induration;  C,  corium;  D,  subcutaneous  tissue;  E,  abscess  formation  aboul 
the  hair  follicles  and  sweat  glands;  F,  central  area  of  necrosis;  G,  deep  extravasation 
of  pus  over  fascia  covering  the  muscle;    H,  deep  fascia  covering  muscle. 

telling  the  patient  to  soak  the  part  in  hot  water.  Frequently  the 
application  of  poultices  directly  over  the  dressing  affords  great  comfort 
and  creates  an  active  hyperemia. 

Carbuncle. — (  arbuncles  occur  practically  always  where  there  is  hair. 
The  common  sites  are  the  back  of  the  neck,  the  back  of  the  hand,  the 
face,  particularly  the  upper  or  lower  lip.  They  are  really  collections  of 
abscesses  that  have  varying  degrees  of  communication  about  a  central 
area  of  necrosis.  They  are  generally  superficial  to  a  deep  collection 
of  pus  that  has,  as  it  were,  mushroomed  out  along  the  deep  fascia 
covering  the  muscular  planes.  These  abscesses  project  along  the  sweat 
glands  and  hair  follicles,  by  way  of  the  fat  bundles  that  surround  them, 


DISEASES  OF  THE  SKIN  199 

toward  the  skin.  The  surface  appearance  of  a  carbuncle  generally 
shows  a  swelling  covered  by  epithelium  presenting  several  small  holes 
exuding  pus.  About  this  area  is  an  indurated  zone  of  considerable 
extent  (Fig.  93). 

Treatment. — The  central  portion  of  a  carbuncle  is  not  sensitive  until 
the  deep  fascia  is  reached.  Small  and  moderate-sized  carbuncles  can 
readily  be  operated  upon  under  novocaine  anesthesia.  Larger  ones 
require  gas  and  oxygen.  A  crucial  incision  should  be  made  completely 
through  the  area  of  induration.  The  flaps  are  then  dissected  free,  so 
that  the  whole  area  of  induration  has  been  thoroughly  undermined. 
This  is  best  done  by  incising  the  skin  with  a  knife  and  completing  the 
incision  with  blunt-pointed  scissors.  In  this  wTay  care  can  be  taken 
not  to  injure  the  deep  fascia  or  the  muscle  that  may  underlie  it.  Drain- 
age and  dressing  are  similar  to  that  of  an  ordinary  abscess.  The  use 
of  a  solution  of  camphor  60,  pure  carbolic  30,  alcohol  10  on  the  gauze 
drain  after  opening  an  abscess  or  carbuncle  (not  its  subsequent 
dressings)  can  be  recommended. 

By  far  the  commonest  place  for  superficial  infections  to  occur  is 
in  the  hand  and  fingers.  In  the  succeeding  pages  a  description  of  the 
surgical  anatomy  and  the  management  of  such  infections  will  be  given. 

Hand  Infections. — In  considering  these  infections  it  is  well  to  have 
an  accurate  knowledge  of  the  surgical  anatomy  and  to  define  and 
describe  the  terminology  that  will  be  used. 

Eponychium. — This  refers  to  those  tissues  covering  the  base  of  the 
nail,  composed  of  a  superficial  layer  of  epithelium,  forming  the  dorsal 
epidermis  of  the  finger,  which,  at  its  distal  free  edge,  is  attached  to  the 
nail,  and  reflected  proximally  to  fuse  wTith  the  proximal  edge  of  the 
nail  matrix  epithelium.  These  twTo  epithelial  layers,  the  superficial 
and  the  reflected,  together  with  a  small  amount  of  cellular  tissue 
between  them,  are  the  eponychium. 

Paronychium. — This  structure  is  in  continuity  with  and  quite  anal- 
ogous to  the  structure  of  the  eponychium  except  that  it  is  situated 
along  the  side  of  the  nail,  is  less  intimately  attached  to  the  nail  distally, 
and  that  the  reflected  edge  is  continuous  with  the  epithelial  layer  of 
the  nail  bed  and  not  continuous  with  the  nail  matrix  epithelium  as 
in  the  eponychium.  The  subcutaneous  tissues,  however,  of  the 
paronychium  and  the  eponychium  are  continuous  and  intimate,  not 
only  anatomically  but  clinically. 

The  Nail. —  The  nail  body  is  that  portion  of  the  nail  which  ex- 
tends from  the  lunula  to  its  free  distal  edge. 

The  nail  base  is  that  portion  of  the  nail  corresponding  to  the  lunula 
and  extending  proximally  into  the  re-entrant  angle  of  epithelium  formed 
by  the  junction  of  the  reflected  layer  of  epithelium  of  the  eponychium 
and  the  epithelium  of  the  nail  matrix.  The  shape  of  the  nail  at  this 
point  is  tapering  or  chisel  shaped,  its  thickest  portion  being  at  the 
distal  margin  of  the  lunula  wmence  it  tapers  proximally  until  it  is  lost 
in  the  re-entrant  angle  above  mentioned,  at  which  point  it  becomes  the 


200 


INJURIES  AND  DISEASES  OF   THE  SKIN 


stratum  lucidum,  to  which  epidermal  layer  the  nail  corresponds. 
Practically,  however,  as  will  be  seen  later,  in  the  removal  of  the  nail 
there  is  an  arbitrary  area  where  the  comparatively  dense  substance  of 
the  nail  becomes  a  delicate  epithelial  film.  This  arbitrary  point  is  a 
short  distance  proximal  to  the  free  edge  of  the  eponychium,  correspond- 
ing to  about  the  middle  of  the  matrix  (see  C,  Fig.  96).  In  various 
pathological  conditions,  such  as  in  subungual  abscesses  and  subungual 
hematoma,  where  the  nail  has  been  separated  from  the  nail  bed  and  the 
nail  matrix,  the  proximal  free  edge  of  the  nail  will  be  found  at  this 


Fig.  94. — Microphotograph  of  transverse  section  of  the  finger  through  the  body 
of  the  nail.  A,  nail;  B,  nail  bed;  C,  subungual  space  with  dilated  bloodvessels;  D, 
shaft  of  distal  phalanx;  E,  dense  corium;  F  and  G,  vertical  arrangement  of  trabecular 
of  the  subcutaneous  tissue;    H,  sweat  glands;    /,  paronychium ;    J ,  nail  sulcus. 


point  and  not  at  the  theoretical  origin  of  the  nail  in  the  re-entrant 
angle  at  the  proximal  portion  of  the  matrix. 

The  Lunula. — This  term  is  given  to  the  white  portion  of  the  nail 
just  distal  to  the  free  edge  of  the  eponychium.  It  corresponds  to 
the  visible  portion  of  the  nail  matrix.  The  cause  of  its  opacity  as 
compared  to  the  translucent  nail  body  is  not  quite  clear.  The  reason 
ascribed  is  that  it  is  due  to  an  inherent  opacity  peculiar  to  the  cells  of 
the  matrix. 

The  Nail  Matrix. — This  is  composed  of  the  epithelial  cells  from 
which  the  nail  grows.     Its  proximal  margin  is  situated  close  to  the 


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DISEASES  OF   THE  SKIN  201 

extensor  tendon  over  the  base  of  the  distal  phalanx,  just  distal  to  the 
interphalangeal  joint.  It  extends  distally  as  far  as  the  lunula.  Incision 
of  the  nail  matrix  should  almost  never  be  necessary  except  for  excision. 
Longitudinal  incision  of  the  nail  matrix  is  most  ill-advised  and  has 
been  the  cause  of  countless  split  nails,  a  permanent  and  irremediable 
deformity  (see  Figs.  97  and  98).  Accordingly,  in  any  possible  instance 
where  it  seems  advisable  to  incise  the  nail  matrix  the  incision  should 
be  made  transversely  rather  than  longitudinally.  By  so  doing,  an 
absolute  thinning  of  the  nail  may  result,  in  most  cases  unnoticeable, 
but  the  deformity  of  a  split  nail  avoided. 

The  trail  bed  is  confined  to  that  layer  of  epithelium  upon  which 
the  nail  body  rests,  from  which  it  derives  its  nutrition,  but  from 
which  it  does  not  grow.  It  is  entirely  distal  to  the  lunula.  This 
epithelium  is  thrown  into  even,  longitudinal,  papillary  ridges. 

Subungual  Space. — This  applies  to  the  subcutaneous  tissues  beneath 
the  nail  bed  and  the  nail  matrix.  It  is  exceedingly  vascular,  and 
in  section  shows  an  enormous  number  of  arterioles.  It  is  particularly 
important  with  reference  to  the  infections  of  the  eponychium,  the 
paronychium  and  the  dense  fibrous  tissue  of  the  extreme  tip  of  the 
finger. 

Anterior  Closed  Spaces. — In  the  thumb  there  are  two,  and  in  the  other 
fingers  three,  that  clinically,  and  to  a  certain  extent  anatomically, 
may  be  called  closed  spaces.  The  flexion  creases  of  the  fingers  are  the 
dividing  line  between  the  anterior  closed  spaces.  In  the  fingers  they 
are  the  distal,  the  middle  and  the  proximal;  in  the  thumb  the  distal 
and  proximal.     (Plate  IV.) 

The  distal  closed  space  is  more  completely  separated  from  the 
middle  closed  space  than  the  middle  from  the  proximal.  The  reason 
for  this  is  because  of  the  large  amount  of  space  taken  up  by  the  head 
of  the  second  phalanx,  the  glenoid  ligament  and  the  flexor  tendons  at 
the  level  of  the  distal  flexion  crease,  thus  reducing  the  distance  from 
the  skin  epithelium  to  the  flexor  tendon  to  a  minimum.  Certain 
features  of  the  architecture  of  these  anterior  closed  spaces  demand 
attention.  In  the  first  place  the  epithelium  of  the  epidermis  is  exceed- 
ingly thick.  Though  there  are  no  hair  follicles  and  sebaceous  glands, 
there  are  a  great  many  sweat  glands  which  penetrate  through  the 
corium  into  the  outer  portion  of  the  subcutaneous  tissue.  The  con- 
nective-tissue trabecule  of  the  subcutaneous  tissue  separating  the  fat 
bundles  have  a  different  arrangement  from  those  trabecule  belonging 
to  the  dorsum  of  the  hand.  They  tend  to  run  at  right  angles  to  the 
skin  in  marked  contradistinction  to  the  dorsum  of  the  finger  where 
the  tendency  is  to  run  parallel  to  the  skin  (F  and  G,  Fig.  94).  These 
connective-tissue  strands  are  very  strong  and  thick,  particularly  at  the 
distal  end  of  the  anterior  closed  space  of  the  distal  phalanx,  where  they 
run  directly  from  the  corium  to  the  end  of  the  phalanx.  It  is  inter- 
esting to  note  the  gradual  transition  from  bone  to  connective  tissue 
at  this  point.     The  middle  anterior  closed  space  is  the  smallest  and 


202  INJURIES  AND  DISEASES  OF  THE  SKIN 

corresponds  to  the  shaft  of  the  middle  phalanx.  The  proximal  anterior 
elosed  space  is  different  from  the  other  two  because  of  the  freedom 
with  which  it  communicates  with  the  palm  of  the  hand  and  the  tissues 
of  the  web  of  the  fingers.  The  free  edge  of  the  web  of  the  ringers  is 
continuous  with  their  anterior  surfaces.  Just  dorsal  to  this  and  along 
the  sides  of  the  fingers  there  is  no  flexion  crease,  nor  is  there  any  limiting 
factor  to  the  extension  from  the  sides  of  the  proximal  closed  space  into 
the  tissues  of  the  web.  Along  this  route  run  the  tendons  of  the 
lumbrical  muscles  and  the  interossei  to  be  inserted  into  the  phalanx  and 
into  the  extensor  tendons.  Close  to  these  tendons  run  the  digital 
vessels  and  nerves,  and  extension  along  this  route  of  a  web  abscess  of 
the  palm  into  the  proximal  closed  space  and  vice  versa  is  a  common 
clinical  sequence.  The  two  digital  vessels  and  nerves  run  along  the 
anterolateral  aspect  of  the  fingers.  It  is  true  that  where  they  enter 
the  distal  anterior  closed  space  they  run  in  rather  a  constricted  portion 
of  the  finger,  though  the  sections  show  that  there  is  more  room  for 
them  than  is  generally  believed,  and  that  direct  pressure  as  they  enter 
the  distal  anterior  closed  space  can  hardly  be  a  primary  factor  in 
cutting  off  the  blood  supply  to  the  distal  phalanx.  It  is  important  to 
recognize  where  the  digital  nerves  enter  the  distal  anterior  closed 
spaces,  inasmuch  as  it  is  often  possible  to  infiltrate  near  them  with 
local  anesthesia  in  operating  on  the  ends  of  the  fingers. 

The  Glenoid  Ligament. — The  glenoid  ligament  is  a  structure  made 
up  of  dense  bands  of  interlacing  fibrous  tissue  situated  on  the  anterior 
surface  of  the  interphalangeal  joints  and  lined  on  its  dorsal  surface  by 
the  synovial  membrane  of  the  joint.  Anterior  to  it  passes  the  flexor 
tendon  which  is  in  intimate  relation  with,  but  not  firmly  attached  to  it. 
The  strongest  attachment  of  the  glenoid  ligament  is  to  the  anterior 
surface  of  the  base  of  the  phalanx  distally.  It  is  of  importance  in  the 
mechanism  of  the  posterior  dislocation  of  the  phalanges. 

The  Extensor  Tendon. — The  extensor  tendon  is  flat  and  more  of  an 
aponeurotic  sheet  than  a  tendon,  is  uneven  in  thickness  at  different 
portions  of  the  finger  and  runs  in  fascial  planes  to  its  insertion  on  the 
dorsal  surface  of  the  distal  phalanx  at  its  base  and  for  a  considerable 
extent  along  its  shaft.  It  is  thickened  over  the  proximal  phalanx, 
where  the  tendons  of  the  interossei  and  lumbrical  muscles  are  inserted. 
It  is  also  thickened  over  the  metacarpophalangeal  and  interphalangeal 
joints,  where  it  serves  to  form  a  portion  of  their  capsules.  This  tendon 
divides  the  dorsal  surface  of  the  finger  into  two  fascial  spaces,  the  first 
called  the  dorsal  subcutaneous  space  and  the  second  the  dorsal 
subaponeurotic  space,  spoken  of  by  Dr.  Kanaval  in  his  book  on 
infections  of  the  hand. 

Finger-end  Infections. — Eponychia. — The  infections  of  the  epony- 
chium  are  generally  situated  slightly  to  one  side  of  the  midline,  are 
often  associated  with  a  paronychia  and  are  commonly  called  "pan- 
aritium" or  "  run-arounds."  From  a  clinical  standpoint  as  well  as 
pathological,  it  is  wise  to  differentiate  two  types.     The  first,  or  simplest 


DISEASES  OF  THE  SKIN  203 

type  of  eponychia  (Fig.  95),  is  that  type  in  which  the  infection  is  con- 
fined  to  the  epithelium  and  subepithelial  tissue  on  the   dorsum   of 


Fig.  95. — Diagrammatic  drawing  to  illustrate  the  superficial  type  of  an  eponychia 
where  there  is  no  extension  to  the  subungual  space.  In  this  type,  no  interference  with  the 
nail  is  necessary.  Clipping  away  the  "roof"  of  the  pus  blister  is  generally  all  the  opera- 
tive treatment  needed.   If  this  does  not  suffice,  a  subungual  extension  should  be  suspected. 

the  nail  base  and  has  not  spread  either  through,  or  proximally,  or 
laterally,  to  beneath  the  nail  matrix  so  as  to  form  a  subungual  abscess. 
This  simple  type  is  easily  treated  by  separating  the  free  epithelial 
edge  of  the  eponychium  from  the  nail  so  that  the  superficial  pus  pocket 


Fig.  96. — Diagrammatic  drawing  to  illustrate  a  severer  type  of  eponychia.  In  this 
instance  the  infection  has  spread  to  the  subungual  space  either  proximal  to  the  matrix 
or  along  its  side,  or  directly  through  it. 

The  nail  has  become  separated  from  its  matrix  epithelium,  and  now  forms  the  roof 
of  a  pus  blister.  It  has  lost  its  nutrition  and  acts  as  a  foreign  body  in  an  abscess  cavity. 
All  the  nail  that  has  separated  must  be  removed  before  healing  will  take  place.  The 
arbitrary  point  where  the  transition  occurs  between  grossly  dense  nail  and  delicate 
stratum  lucidum  of  the  epithelium  is  indicated.  This,  and  not  the  theoretically  proximal 
extremity  of  the  nail  in  the  re-entrant  angle  made  by  the  matrix  and  the  reflected  epithe- 
lium of  the  eponychium,  is  the  proximal  free  edge  of  the  nail  when  it  separates.  Acute 
flexion  of  the  phalanx  often  displaces  this  free  edge  dorsal  to  the  eponychium,  facili- 
tating removal  without  incision.  A,  subungual  abscess;  B,  eponychia;  C,  proximal 
free  margin  of  nail  after  separation. 

receives  adequate  drainage.     No  interference  with  the  nail  is  necessary 
in  this  condition.     The  second,  or  more  serious  type  of  eponychia, 


204  INJURIES  AND  DISEASES  OF  THE  SKIN 

is  that  in  which  the  infection  has  spread,  either  through  the  nail 
matrix,  near  its  proximal  end,  or  around  its  proximal  or  lateral  free 
edge  into  the  subungual  space.  In  this  instance,  the  nutrition  of  the 
nail  is  interfered  with  and  it  becomes  separated  from  its  matrix.  By 
referring  to  the  diagram  (Fig.  96)  it  will  be  seen  that  the  nail  having 
separated  from  the  matrix,  projects  as  a  free  edge,  which  occurs  at 
an  arbitrary  line,  about  half  way  down  the  matrix,  into  an  abscess 
cavity,  and  acts  as  an  irritating  foreign  body.  Failure  to  remove 
that  portion  of  a  nail  which  has  separated  from  its  bed  or  matrix,  and 
has  accordingly  lost  its  nutrition,  is  dead,  and  is  acting  as  an  irritating 
foreign  body,  is  by  far  the  commonest  cause  of  the  long  duration  of 
many  of  this  type  of  finger  infection.  The  diagnosis  of  a  subungual 
extension  is  generally  made  on  two  points,  one  in  the  history — an 
eponychia  or  paronychia  that  refuses  to  get  well,  or  has  had  a  duration 
of  more  than  two  or  three  days  without  treatment.  The  other  point 
rests  upon  a  very  careful  inspection  of  the  nail,  after  cleansing,  for  any 
injected  appearance  of  the  subungual  space  through  the  nail  or  opacity 
or  inequality  in  color.  It  is  not  infrequent  to  be  able  to  notice  that 
the  lunula  is  asymmetrical.  Tenderness,  such  an  extremely  important 
guide  in  other  respects  in  finger  infections,  is  of  little  avail  and  is  of 
not  as  much  value  in  diagnosis  of  subungual  abscess  as  the  history  and 
the  appearance  of  the  nail. 

Paronychia. — The  same  general  remarks  as  to  eponychia  apply  to 
paronychia,  inasmuch  as  antomically  they  are  very  similar.  On  the 
other  hand,  paronychial  extensions  extend  to  the  subungual  space 
beneath  the  nail  bed,  instead  of  the  nail  matrix.  It  may  be  well  to 
mention  a  clinical  fact  at  this  point,  namely,  that  the  association  of  a 
paronychia  with  a  distal  anterior  closed  space  abscess  is  a  rare  con- 
dition. Paronychias  do  not  easily  extend  to  the  anterior  closed  space, 
nor  do  anterior  closed  space  abscesses  extend  to  the  paronychium,  and 
many  unnecessary  incisions  have  been  made  either  in  the  paronychium 
or  in  the  anterior  space.  Paronychia  is  almost  a  constant  associate 
with  ingrowing  toe-nail. 

Treatment  of  Severe  Eponychia  and  Paronychia. — In  simple  paronychia 
as  in  simple  eponychia  the  reflected  epithelium  should  be  pushed  or 
separated  in  any  way  from  the  surface  of  the  nail  and  broken  through 
near  its  deep  attachment.  At  this  point  the  instrument  will  open  into 
the  abscess.  If  the  abscess  in  a  paronychia  has  extended  beneath 
the  nail  along  the  body  of  the  nail,  that  portion  of  the  nail  edge  that 
has  separated  from  the  nail  bed  and  is  acting  as  a  foreign  body  in  the 
wall  of  the  abscess  should  be  removed  to  the  point  where  the  nail  is 
found  to  be  attached  to  the  nail  bed.  In  eponychia  and  in  paronychia 
where  the  abscess  has  extended  to  the  subungual  space  beneath  the 
nail  matrix  the  so-called  paronychial  incision  will  sometimes  have  to 
be  made.  This  incision  is  simply  an  extension  proximally  along  the 
lateral  nail  sulcus  with  a  result  that  the  reflected  epithelium  of  the 
paronychium  or  the  eponychium,  as  the  case  may  be,  is  incised;  but 


DISEASES  OF  THE  SKIN 


205 


no  incision  is  made  through  the  nail  matrix  nor  through  the  nail 
bed  at  any  point  (Fig.  97).  The  nail  where  it  has  separated  from 
its  epithelium  is  then  removed,  and  drainage  instituted.  It  is  well 
to  note  that  removal  of  the  base  of  the  nail  alone  without  any  incision 
will  suffice  in  many  more  cases  than  is  generally  supposed. 

Subungual  Space  Abscess. — This  may  occur  anywhere  underneath 
the  nail  and  has  already  been  spoken  of  with  reference  to  eponychia  and 


Fig.  97 


Fig.  98 


Fig.  97. — Photograph  of  a  cleft  nail  due  to  an  old  injury  to  the  nail  matrix.  This 
injury  occurred  in  a  postman  many  years  previously.  During  winter  the  cleft  would 
extend  to  the  base  of  the  nail  and  remain  wide  open;  during  summer  with  improvement 
in  the  circulation  the  cleft  would  almost  close.  A,  "paronychial  incision"  for  parony- 
chia or  eponychia,  where  an  incision  is  required.    This  will  avoid  a  "cleft  nail." 

Fig.  98. — Photograph  of  a  cleft  nail  due  to  an  old  injury  to  the  matrix  with  no 
apparent  scar  of  eponychium. 

paronychia.  Where  it  occurs,  however,  away  from  these  two  points, 
for  instance,  when  caused  by  a  splinter  or  needle  entering  the  end  of  the 
finger  just  beneath  the  nail,  as  is  shown  in  Fig.  99,  the  nail  has  been 
separated  from  its  bed  to  a  varying  extent  and  pus  may  even  be  seen 
through  it.  Having  at  this  point  lost  its  nutrition  the  nail  is  useless 
and  should  be  removed.  In  this  instance  the  nail  is  forming  the  roof 
of  a  blister,  and  when  removed  the  shiny,  glistening  nail-bed  epithelium 
will  be  seen  beneath,  after  the  pus  has  been  sponged  away.     There 


206  INJURIES  AND  DISEASES  OF   THE  SKIN 

will  often,  however,  be  a  small  spot  of  necrosis  of  nail  bed  epithelium, 
or  it  may  be  of  considerable  size,  leading  into  an  abscess  cavity  in  the 
subungual  space.  Accordingly,  it  will  be  seen  that  many  of  these 
abscesses  are  clearly  of  the  collar-button  or  dumb-bell  type,  and  the 
rule  to  always  remove  the  entire  roof  of  a  pus  blister  holds  good.  It 
is  clinically  a  fact  that  a  subungual  abscess  is  very  rarely  associated 
with  bone  involvement,  with  the  exception  of  those  which  occur  at 
the  extreme  tip  of  the  phalanx,  where  the  dense  connective-tissue 
fibres  are  so  intimately  attached  to  the  tip  of  the  phalanx. 

Ingrowing  Toe-nail. — A  so-called  ingrowing  toe-nail  is  caused  by 
one  or  more  of  the  following  factors,  alone  or  in  combination :  High  heel, 
pointed  shoes,  too  short  shoes.  Pressure  on  the  side  of  the  toe  against 
the  lateral  edge  of  the  nail  causes  trauma  to  the  reflected  layer  of 
paronychia!  epithelium  in  the  nail  sulcus.     Infection  results.     ^Yith 


Fig.  99. — Diagrammatic  drawing  of  a  subungual  abscess  frequently  seen  where 
splinters  or  needles  have  been  run  into  the  end  of  the  finger.  In  this  case  the  nail, 
forming  the  "roof"  of  a  pus  blister,  is  dead,  and  should  be  removed  wherever  it  has 
been  separated  from  its  bed,  whence  it  receives  its  nutrition.  Usually  after  removal  of 
the  nail,  a  small  sinus  opening  can  be  seen  leading  through  the  nail  bed  epithelium  into 
the  subungual  space,  e.  g.,  a  "collar-button"  abscess.  Removal  of  the  nail  is  generally 
enough  for  drainage. 

rest  and  cleanliness  the  infection  disappears,  but  the  trauma  may 
thus  be  repeated  so  often  and  infection  follow  infection  with  such 
rapidity  that  scarring  of  the  tissues  of  the  paronychium  ensues.  The 
paronychium  may  thus  become  hyperplastic  and  considerably  larger 
than  normal.  There  generally  is  a  chronic  paronychia.  Children 
outgrowing  their  shoes  may  be  subjected  to  this  trauma.  Close 
clipping  of  either  of  the  distal  free  corners  of  the  nail  may  also  subject 
the  soft  parts  to  trauma  against  the  close  cut,  partially  buried,  free 
edge. 

Treatment. — The  majority  of  these  cases  may  be  permanently 
cured  by  cleanliness  and  advice  as  to  the  correct  shoe.  Occasionally, 
however,  the  condition  has  obtained  for  such  a  long  time  that  the 
architecture  of  the  side  of  the  toe  has  been  distorted  to  a  more  or  less 
permanent  degree.  In  such  cases  operation  will  give  speedy  and 
permanent  relief. 


DISEASES  OF   THE  SKIN 


207 


Operation  for  Ingrowing  Toe-nail.-  -The  object  of  the  operation  is 
to  permanently  narrow  the  nail.  This  is  done  by  removing  the  side 
of  the  nail,  the  nail  bed  and,  most  important  of  all,  the  nail  matrix. 
A  simple  way  of  doing  this  is  indicated  in  the  diagrams  (Fig.  100). 
It  is  important  for  one  or  two  days  before  the  operation  to  clean  the 
field  of  operation  as  thoroughly  as  possible,  applying  a  sterile  dressing. 
After  applying  a  rubber  tourniquet  and  under  local  anesthetic,  prefer- 
ably novocaine,  a  slightly  curved  incision  is  made  along  the  nail 
sulcus  through  the  eponychium.     This  gives  a  good  exposure  to  the 


II 


in 


Fig.  100. — Operation  fur  ingrowing  toe-nail.  I,  illustration  of  a  skin  incision  well 
adapted  to  expose  the  proximal  lateral  corner  of  the  nail  matrix:  the  matrix  epithelium 
at  this  ]>"iiit  i-  sometimes  not  completely  removed,  with  a  consequent  failure  to  effect 
a  permanent  cure:  o,  proximal  and  lateral  corner  of  the  nail  matrix.  II,  the  flaps  have 
been  dissected  back  leaving  the  reflected  layer  of  epithelium  from  the  eponychium  and 
the  paronychium  attached  to  that  portion  of  the  nail  to  be  removed.  The  nail,  the  nail 
bed.  and  the  nail  matrix  corresponding  to  the  shaded  area  are  excised  as  one  piece. 
Thus  granulating  surfaces  of  the  flaps  come  in  contact  with  the  granulating  surface  of 
the  subungual  space.  777,  after  the  excised  tissues  have  been  removed,  the  flaps,  with 
their  raw  surfaces  against  the  exposed  subungual  space,  fall  together  as  indicated. 
Observe  that  the  oblique  incision  of  the  matrix  should  theoretically  cause  the  permanent, 
lateral,  nail  edge  to  resemble  the  normal  " chisel  edge"  shape  of  the  normal  nail,  thus 
causing  a  gradual  transition  between  the  nail  edge  and  skin  epithelium:  a,  area  of  nail 
left  for  temporary  protection,  that  will  ultimately  disappear:  b,  nail  growing  from  this 
portion  of  matrix  very  thin;  c,  nail  growing  from  this  portion  of  matrix  thicker;  d, 
nail  growing  from  this  portion  of  matrix  normal  thickness. 


proximal  and  lateral  corner  of  the  nail  matrix.  The  corresponding 
eponychial  and  paronychial  flaps  are  liberated  with  a  knife  in  such  a 
way  that  their  reflected  layers  of  epithelium  will  be  left  on  that  portion 
of  the  nail  subsequently  to  be  excised.  This  leaves  a  granulating 
surface  to  come  in  contact  with  the  granulating  surface  exposed  after 
resection  of  the  nail,  its  bed  and  its  matrix.  The  latter  are  removed 
by  an  oblique  incision  extending  from  the  distal  corner  of  the  nail 
through  the  matrix  nearer  the  median  line.  It  is  possible  to  be  sure 
that  all  the  matrix  epithelium  has  been  removed  if  a  small  amount  of 


208 


INJURIES  AND  DISEASES  OF   THE  SKIN 


areolar  tissue  be  seen  with  its  accompanying  fat  outside  of  the  proxi- 
mal corner.  Should  this  proximal  corner  of  matrix  epithelium  be  left, 
the  wound  will  either  not  heal  or  there  will  be  a  recurrence  of  the 
original  condition  through  the  growth  of  the  nail  from  the  remaining 
portion  of  matrix.  The  flaps  may  then  be  sutured  with  one  very  fine 
silkworm-gut  suture,  the  tourniquet  removed  and  gentle  pressure  made 
to  control  the  hemorrhage  before  permanent  dressing  is  applied.  After 
a  short  time  the  bleeding  will  practically  stop. 

Distal  Anterior  Closed  Space  Abscess. — This  is  the  lesion  generally 
spoken  of  as  a  felon.  It  is  one  of  the  commonest  places  for  a  "collar- 
button  abscess."  The  collar-button  abscess  in  this  instance  is  a 
superficial  pus  blister  communicating  by  a  small  sinus  through  the 
epidermis  and  corium  with  a  deeper  abscess  in  the  subcutaneous 
tissue  (Fig.  101). 


Fiu.  101. — "Collar-button"  abscess  of  the  anterior  closed  space.  The  pus  blister 
may  be  large  and  the  deep  abscess  small,  as  in  this  diagram,  or  vice  versa.  There  may 
be  more  than  one  sinus  between  the  blister  and  abscess.  A,  deep  abscess;  B,  sinus; 
C,  pus  blister;    D,  so-called  "roof"  of  the  pus  blister. 


The  pus  blister  may  be  large  and  the  abscess  small,  or  nice  versa. 
Many  times  these  abscesses  are  incompletely  opened  simply  because 
the  rule  to  remove  the  whole  of  the  roof  of  a  pus  blister  has  not  been 
observed,  and  the  small  sinus  leading  into  the  real  abscess  has  been 
overlooked.  Always  remove  the  whole  roof  of  a  pus  blister.  Several 
sinuses  may  open  under  the  roof  of  one  pus  blister.  After  the  removal 
of  the  roof  of  the  blister  the  real  abscess  in  the  cellular  tissues  may 
then  be  drained.  In  abscess  formation  of  the  anterior  closed  space 
it  is  the  fat  bundles  that  earliest  liquefy,  and  it  is  in  these  cavernous 
spaces  walled  off  from  one  another  by  the  strong  bands  of  connective 
tissue  running  perpendicularly  from  the  skin  in  which  pus  accumulates. 
The  connective  tissue  separates  later  with  difficulty.  Careful  study 
of  the  area  of  tenderness  is  the  best  guide  to  the  size  of  the  cavity 
and  method  of  treatment.  The  commonest  complication  of  an  anterior 
closed  space  abscess  is  infection  of  the  bone  of  the  distal  phalanx. 
It  is  very  rarely  associated  with  paronychia  and  eponychia  or  subungual 
abscess,  but  may  become  so  through  neglect  or  injudicious  incision. 


DISEASES  OF   THE  SKIN 


209 


Treatment. — Certain  collar-button  abscesses  have  a  very  small,  deep 
abscess.  If  the  area  of  tenderness  has  been  small  and  after  completely 
removing  the  blister  roof  a  probe  gently  introduced  through  the 
sinus  evacuates  only  a  drop  or  so  of  pus,  chemical  drainage  by  the 
use  of  pure  carbolic  is  indicated.  This  is  done  in  the  following  manner. 
The  pure  carbolic  crystals,  liquefied  by  heat,  are  used,  weaker  solutions 
being  less  efficacious.  It  is  applied  on  the  end  of  a  pointed  wooden 
toothpick  directly  into  the  sinus  opening.  After  the  anesthetic  action 
is  noted  a  gradually  increasing  circular  motion  about  the  wall  of  the 
sinus  will  coagulate  and  shrivel  up  the  tissues  so  as  to  enlarge  the  lumen 
and  secure  adequate  drainage.  Care  must  be  taken  to  penetrate 
the  corium  and  really  enter  the  abscess.     Disregard  of  this  has  caused 


Fig.  102. — Diagrammatic  drawing  illustrating  the  lateral  incision  into  an  abscess 
of  the  anterior  closed  space.  Observe  that  the  subcutaneous  tissue  trabecular  are  cut 
across,  allowing  free  drainage  of  both  the  deep  and  superficial  fat  bundles.  The  point 
of  the  knife  should  be  directed  more  towards  the  surface  than  towards  the  deeper 
structures,  to  avoid  injury  of  main  bloodvessels. 


many  failures.  The  deep  wall  of  the  abscess  should  not  be  traumatized. 
Small  gutta-percha  tissue  drains  with  or  without  small  pieces  of  cotton 
tape  or  string  dipped  in  pure  carbolic  and  excess  removed  are  cut  to 
fit  the  size  of  the  sinus  and  inserted  into  the  abscess.  Outside  of  this 
is  placed  the  dressing.  In  the  treatment  of  larger  abscesses  incision 
in  the  midline  should  be  avoided  if  possible.  It  should  be  made  along 
the  side  of  the  anterior  closed  space  (Fig.  102). 

The  question  arises  as  to  where  to  make  the  incision  in  those  cases, 
and  they  are  quite  frequent,  in  which  there  is  a  collar-button  infection 
and  sinus  in  the  midline  of  the  finger.  In  an  abscess  of  any  size  it 
is  better  to  disregard  the  collar-button  sinus  entirely  and  make  the 
usual  lateral  anterior  closed  space  incision  into  the  abscess  from  the 
side.  After  so  doing  the  sinus  of  the  collar-button  infection  epithe- 
14 


210  INJURIES  AND  DISEASES  OF   THE  SKIN 

lializes  across  rapidly  with  a  minimum  amount  of  scar  for  the  pulp 
of  the  finger. 

Abscess  of  the  Distal  Anterior  Closed  Space,  with  Osteomyelitis  of 
the  Distal  Phalanx. — There  are  several  theories  elaborated  to  account 
for  the  frequency  of  bone  infection  in  distal  anterior  closed  space 
abscesses.  On  examining  a  series  of  sections  made  in  the  lateral 
plane  of  the  finger,  the  blood  supply  of  the  distal  phalanx  can  be 
seen  to  be  derived  from  branches  of  the  two  digital  vessels  that  unite 
as  an  arch  just  proximal  to  the  thickened  tip  of  the  phalanx.  From 
this  arch  run  smaller  branches  through  definite  openings  in  the  shaft. 
Proximal  to  these  openings  the  anterior  surface  of  the  phalanx  is 
covered  by  the  insertion  of  the  flexor  profundus  tendon.  No  openings 
of  such  magnitude  are  to  be  observed  on  the  dorsum  of  the  bone. 
Through  these  openings  infection  may  readily  extend  directly  into  the 
medullary  cavity  of  the  diaphysis  (Fig.  103).     It  is  at  precisely  this 


Fig.  103. — Diagrammatic  drawing  of  an  abscess  of  the  anterior  closed  space,  with 
osteomyelitis  of  distal  phalanx.  Note  that  that  portion  of  the  bone  most  frequently 
and  most  extensively  involved  is  near  the  entrance  of  the  bloodvessels  to  the  diaphysis. 
This  is  what  is  commonly  known  as  a  "  bone  felon."  A,  point  of  entrance  of  diaphyseal 
bloodvessels. 

point  that  necrosis  of  the  bone  is  most  frequent.  The  proximal  or 
epiphyseal  end  of  the  bone,  on  the  other  hand,  is  supplied  by  branches 
which  come  from  the  main  digital  vessels  at  the  level  of  the  joint. 
These  branches  run  between  the  tendon,  the  distal  end  of  the  glenoid 
ligament  and  the  bone,  entering  the  bone  as  tiny  vessels  just  distal 
to  the  insertion  of  the  capsular  ligament.  These  vessels  are  separated 
from  an  abscess  of  the  anterior  closed  space  by  the  flexor  tendon  and 
the  glenoid  ligament.  Infection  of  the  epiphyseal  end  of  the  phalanx 
is  therefore  generally  associated  either  with  an  infection  near  the  joint 
or  a  neglected  anterior  closed  space  infection  Avith  osteomyelitis 
and  direct  extension  along  the  medullary  cavity  of  the  diaphysis. 
In  these  cases  there  is  generally  an  extension  of  the  infection  into  the 
joint. 

An  interesting  type  of  finger  infection  in  neglected  and  untreated 
felon  cases  has  been  observed.     These  cases  have  acted  so  similarly 


DISEASES  OF  THE  SKIN 


211 


that  it  seems  justifiable  to  characterize  them  as  a  type.  The  process 
starts  as  a  severe  anterior  closed  space  abscess;  later  there  is  bone 
infection  of  the  diaphysis  extending  to  the  epiphysis,  thence  extending 
to  the  interphalangeal  joint.  Besides  these  lesions  there  is  a  dorsal 
abscess  over  the  posterior  surface  of  the  joint  (Fig.  104).  This  dorsal 
abscess  simulates  in  many  ways  an  eponychia  complicated  with 
subungual  abscess.  The  mistake  of  considering  it  such  is  easy  to 
make  and  an  unnecessary  paronychial  incision  may  be  made.  The 
course  of  the  infection  is  clear  with  the  exception  of  the  dorsal  abscess. 
By  what  route  this  extension  to  the  dorsum  occurs  is  hard  to  say. 
It  is  probably  through  the  joint.  Its  situation  is  in  the  subcutaneous 
space  over  the  joint  and  dorsal  to  the  extensor  tendon. 

In  the  regeneration  of  bone  following  osteomyelitis  of  the  distal 
phalanx,  osteogenetic  cells  are  often  found  along  the  dorsum  and  the 
sides  of  the  shaft,  especially  near  its  proximal  end  where  the  two 


Fig.  104. — Diagram  of  a  type  of  anterior  closed  space  abscess,  with  osteomyelitis 
of  the  terminal  phalanx,  suppurative  arthritis  of  the  distal  interphalangeal  joint,  with 
dorsal  abscess  over  the  joint.  The  dorsal  abscess  should  be  differentiated  from  an 
eponychia  with  subungual  abscess. 

tendons,  extensor  and  flexor,  are  inserted.  Where  practically  the 
whole  of  the  diaphysis  has  sequestrated  the  radiograph  may  show  only 
the  faintest  streak  along  the  dorsum;  but  two  or  three  months  later  a 
radiograph  may  show  extensive  regeneration  of  bone  forming  a  phalanx 
of  almost  normal  size.  The  greatest  care  should  be  taken  to  preserve 
intact  as  much  of  the  tissues  surrounding  a  sequestrated  piece  of  bone 
as  possible. 

Suppurative  Arthritis  of  Interphalangeal  and  Metacarpophalangeal 
Joints. — These  infections  are  due  to  wounds  into  joint,  extensions 
from  neighboring  infections,  and,  in  the  metacarpophalangeal  joint, 
often  from  a  laceration  produced  by  the  blow  of  a  closed  fist  against 
teeth.  Though  these  infections  are  generally  staphylococcic  in  origin, 
those  caused  by  a  blow  against  teeth  may  be  infected  by  various 
organisms  indigenous  to  the  mouth  cavity  that  may  cause  a  persistent 
and  very  foul  necrosis.  The  treatment  should  be  conservative. 
Drainage  should  be  established,  if  possible  through  the  wound,  or  by 


212  INJURIES  AND  DISEASES  OF   THE  SKIN 

an  extension  preferably  to  one  or  both  sides  of  the  extensor  tendon. 
The  whole  finger  should  be  immobilized  by  a  splint  in  extension. 
By  traction  over  the  end  of  the  splint  with  an  elastic  extension  appa- 
ratus, thus  keeping  the  ends  of  the  bone  apart,  by  the  careful  removal 
of  small  sequestrated  pieces  of  bone  or  cartilage,  by  the  use  of  the  silver 
nitrate  stick  and  pure  carbolic  along  sinuses  in  which  exuberant 
granulations  are  prone  to  block  drainage,  anchylosis  often  may  be 
avoided  and  a  limited  degree  of  motion  be  preserved,. 

Abscess  of  the  Middle  Anterior  Closed  Space. — The  treatment  of 
these  abscesses  should  be  by  an  anterolateral  incision  on  whichever 
side  of  the  tendons  the  abscess  is  worse.  Should  the  abscess  involve 
the  whole  of  the  middle  anterior  closed  space,  it  is  better  to  make  an 
anterolateral  incision  on  either  side  rather  than  to  try  to  drain 
across  the  tendons.  This,  however,  is  not  as  often  necessary  as  it  is 
in  the  abscess  of  the  proximal  closed  space. 

Abscess  of  the  Proximal  Closed  Space. — These  abscesses  are  often 
associated  with  subcutaneous  abscesses  at  the  base  of  the  finger  in 
the  palm,  or  with  web  infections  between  the  affected  and  contiguous 
fingers.  The  diagnosis  from  digital  tenosynovitis  is  sometimes 
difficult,  but  absence  of  exquisite  tenderness  over  the  tendon  sheath 
in  the  second  phalanx  will  generally  eliminate  a  tendon  sheath  infec- 
tion. Anterolateral  incision,  such  as  has  been  described  in  middle 
anterior  closed  space  abscesses,  should  be  made.  Particular  care  should 
be  taken,  however,  not  to  continue  the  incision  through  the  flexion 
crease  into  the  palm,  inasmuch  as  a  serious  contracture  of  the  finger 
may  result.  This  is  true  to  a  certain  degree  of  the  other  two  closed 
spaces,  but  particularly  true  here. 

Subcutaneous  Abscesses  at  the  Base  of  the  Fingers  and  Web — 
Abscesses  of  Palm.— It  is  important  to  understand  the  arrangement  of 
the  palmar  fascia  in  dealing  with  these  abscesses.  Starting  from  the 
palmaris  longus  and  its  attachment  in  the  lower  edge  of  the  annular 
ligament,  it  spreads  out  distally,  fusing  with  the  deep  fascia  covering 
the  thenar  and  hypothenar  muscles  on  either  side.  It  is  well  to  think 
of  it  as  made  up  of  anterior  fibres  that  run  longitudinally  and  corre- 
spond to  the  fibres  of  the  palmaris  longus  and  posterior  fibres  that 
run  transversely  of  obliquely  and  correspond  to  the  fibres  of  the 
annular  ligament  (Fig.  105).  The  longitudinal  fibres  run  in  four  slips 
to  the  bases  of  the  four  inner  fingers.  The  arrangement  of  the  trans- 
verse and  diagonal  fibres  is  more  complex.  At  the  level  of  the  meta- 
carpophalangeal joint,  and  just  proximal  to  it,  is  the  transverse  meta- 
carpal ligament  (Fig.  106,  C)  made  up  of  a  band  of  transverse  fibres 
about  1  cm.  broad  that  is  just  superficial  to  the  proximal  ends  of  the 
digital  tendon  sheaths.  On  either  side  of  the  flexor  tendons  run  slips 
that  fuse  with  the  deep  palmar  ligament  which  is  the  distal  margin  of 
the  aponeurotic-like  fascia  covering  the  palmar  aspect  of  the  interossei 
and  inserted  into  the  sides  of  the  heads  of  the  metacarpals,  acting  as 
an  interosseous  ligament.     Between  the  tendons  at  this  level  there  is 


DISEASES  OF  THE  SKIN 


213 


a  space  bounded  anteriorly  by  the  transverse  metacarpal  ligament, 
posteriorly  by  the  deep  palmar  ligament  covering  the  palmar  interossei, 
and  on  either  side  by  slips  from  the  transverse  metacarpal  ligament 
to  the  interosseous  fascia,  containing  the  digital  vessels  and  nerves 
and  the  lumbrical  muscles  (Fig.  106). 

More  distally,  to  form  the  web  of  the  finger,  run  other  transverse 
fibres  that  fuse  with  the  free  interdigital  edge  of  the  dorsal  aponeurosis 


Fig.  105. — Illustration  from  Poirier,  showing  the  palmar  fascia.  Observe  that  the 
longitudinal  fibres  corresponding  to  the  palmaris  longus  tendon  are  superficial  and  the 
deep  fibres  corresponding  to  the  annular  ligament  are  transverse.  A,  four  longitudinal 
slips;  B,  transverse  fibres  forming  a  part,  of  superficial  palmar  interosseous  ligament; 
C,  transverse  metacarpal  ligament;  D,  palmaris  longus. 

to  form  the  superficial  palmar  ligament  with  insertion  into  the  sides 
of  the  bases  of  the  neighboring  proximal  phalanges  just  anterior  to 
the  lumbrical  tendon. 

Corresponding  to  the  same  plane  as  the  palmar  fascia  are  the  so-called 
ligamenta  vaginalia  of  the  fingers.  These  are  diagonal  and  transverse 
fibres,  scarcely  noticeable  over  the  joints  but  very  thick  and  strong 
over  the  shafts  of  the  phalanges,  binding  the  flexor  tendons  and  their 
sheaths  to  the  phalanges  and  preventing  prolapse  on  flexion.     They 


214 


INJURIES  AND  DISEASES  OF   THE  SKIN 


are  practically  annular  ligaments  and  will  be  termed  the  phalangeal 
annular  ligaments. 

It  is  not  uncommon  among  men  who  work  with  shovels  or  tools  that 
cause  trauma  to  the  palm  of  the  hand  to  have  abscesses  that  often 
develop  beneath  callous  spots  at  the  base  of  the  fingers.  They  are 
tender  and  cause  considerable  pain  but  often  show  very  few  surface 
signs.  Occasionally  there  is  a  pus  blister  involving  the  calloused 
epidermis.  They  occur  either  over  the  tendon  or  between  the  fingers, 
or  both.  The  important  feature  to  recognize  is  that  they  may  exist 
on  both  sides  of  the  palmar  fascia,  which  in  this  instance  is  largely 


Fig.  106. — Diagrammatic  drawing  of  the  fascial  compartments  of  the  hand  at  the 
level  of  the  transverse  metacarpal  ligament,  to  illustrate  the  situations  and  extensions 
of  subcutaneous  and  web  abscesses  of  the  palm.  A,  flexor  tendons  in  their  sheaths; 
B,  longitudinal  slips  of  the  palmar  fascia  to  the  four  inner  fingers;  C,  transverse  meta- 
carpal ligament  with  prolongations  to  the  sides  of  metacarpal  bones  fusing  with  the 
deep  palmar  interosseous  ligament;  D,  digital  vessels  and  nerve;  E,  dorsal  epidermis; 
F,  fascia  covering  the  interosseous  muscle  which,  slightly  distal  to  this  point,  becomes 
the  deep  palmar  interosseous  ligament;  G,  lumbrical  muscle  in  its  canal;  H,  subcu- 
taneous tissue  showing  the  dense  trabecule  running  from  the  palmar  fascia  to  the 
corium;    /,  palmar  epidermis. 


made  up  of  the  transverse  metacarpal  ligament,  and  in  this  way  may 
be  of  the  "collar-button"  or  "dumb-bell"  type.  By  reference  to  the 
diagrams  (Figs.  106  and  107)  it  may  be  seen  that  such  an  infection  may 
pocket:  (1)  As  a  pus  blister  in  the  epidermis;  (2)  as  an  abscess  in  the 
subcutaneous  tissue;  (3)  as  an  abscess  between  the  transverse  meta- 
carpal ligament  and  the  tendon  sheath;  (4)  as  an  abscess  between 
the  tendons  in  the  space  occupied  by  the  lumbrical  muscles  and  digital 
vessels;  (5)  distally  in  the  tissues  of  the  web  and  (6)  exceptionally  on 
the  dorsum  of  the  hand,  probably  along  the  course  of  the  anterior 
perforating  vessels,  or  by  direct  extension  from  the  web. 


DISEASES  OF  THE  SKIN 


215 


Treatment. — Treatment  of  those  abscesses  directly  over  the  tendon 
and  confined  to  the  subcutaneous  tissues  should  be  by  incision  over 
the  maximum  point  of  tenderness,  avoiding  the  flexion  crease  separat- 
ing the  palm  from  the  proximal  phalanx.  A  good  light  and  retraction 
are  of  use  in  tracing  and  adequately  draining  the  many  pockets  that 
may  occur  in  this  type  of  infection.  Should  the  maximum  points 
of  tenderness  be  on  either  side  of  the  finger,  incision  should  be  made  in 
the  web,  directly  between  the  fingers,  and  if  the  abscess  extends  to 
the  dorsum  the  web  may  be  cut  through.  It  is  unwise,  however, 
to  make  a  web  incision  communicate  with  the  anterolateral  incision 
of  the  proximal  closed  space,  owing  to  the  severe  form  of  contracture 


Fig.  107. — Diagrammatic  drawing  of  the  fascial  compartments  of  the  hand  at  the 
level  of  the  transverse  metacarpal  ligament,  to  illustrate  the  situations  and  extensions 
of  subcutaneous  and  web  abscesses  of  the  palm.  A,  extension  in  subcutaneous  tissue 
between  tendons;  B,  two  routes  of  extension  into  lumbrical  canal;  infection  in  this  space 
extending  proximally  enters  the  thenar  or  mid-palmar  space;  extending  distally,  may 
enter  the  proximal  anterior  closed  space;  C,  extensor  tendons;  D,  dorsal  aponeurosis; 
E,  interosseous  muscles;  F,  extension  beneath  transverse  metacarpal  ligament  about 
tendon  sheath;  G,  collar- button  abscess;  H,  pus  blister. 


liable  to  result.  These  incisions  had  better  be  made  separately  and  a 
small  bridge  of  tissue  left  between. 

Tendon  Sheath  and  Fascial  Space  Infection. — It  cannot  be  too 
strongly  urged  that  anyone  contemplating  treating  hand  infections, 
and  in  particular  those  dealing  with  the  tendon  sheaths  and  fascial 
spaces,  should  study  the  work  of  Dr.  A.  B.  Kanavel  on  "Infections  of 
the  Hand."  Particularly  important  is  it  that  a  clear  understanding 
of  the  surgical  anatomy  of  the  tendon  sheaths  and  fascial  spaces  be  had. 

The  accompanying  diagrams  of  Dr.  Kanavel  show  eight  sections 
of  the  hand  made  about  1  cm.  apart.  The  three  flexion  creases  of  the 
palm  should  be  noted  as  superficial  landmarks  (Fig.  108).     The  first 


216 


INJURIES  AND  DISEASES  OF   THE  SKIN 


diagram  (Plate  V,  Fig.  1)  shows  the  flexor  tendons  in  their  synovial 
sheaths  at  the  level  of  the  shafts  of  the  proximal  phalanges.  Two  fascial 
spaces,  the  dorsal  subaponeurotic  space  and  the  dorsal  subcutaneous 
space  are  shown.  The  subcutaneous  space  is  that  fascial  space  that  is 
separated  from  the  subcutaneous  areolar  tissue  by  the  superficial  layer 
of  the  dorsal  aponeurosis.  The  digital  vessels  and  nerves  are  seen  along 
the  anterolateral  aspects  of  the  fingers.  In  the  second  diagram  (Plate  V, 
Fig.  2)  appear  the  tendons  of  the  lumbrical  muscles,  and  the  interosseous 
muscles.  It  is  important  to  note  the  close  proximity  of  the  lumbrical 
muscles  to  the  digital  vessels  and  nerves.     It  is  along  the  digital 


Fig.  108. — Drawing  made  from  specimen  showing  sites  of  the  various  sections  taken 
through  the  hand.     (Kanavel.) 


vessels  and  the  lumbrical  muscles  that  infections  travel  to  the  deep 
fascial  spaces  of  the  hand,  later  to  be  described.  The  third  diagram 
(Plate  VI,  Fig.  1),  at  the  level  of  the  distal  ends  of  the  metacarpal 
bones  shows  the  dorsal  aponeurosis  including  the  extensor  tendons 
separating  the  dorsal  subcutaneous  from  the  dorsal  subaponeurotic 
space  and  its  relation  to  the  fascial  planes  investing  the  interosseous 
muscles.  The  flexor  tendons  are  still  enclosed  in  their  digital  synovial 
sheaths,  and  the  lumbrical  muscles  with  the  vessels  are  shown  on 
the  radial  side  of  the  fingers  to  which  they  belong.  In  the  fourth 
diagram  (Plate  VI,  Fig.  2)  the  dorsal  fascial  spaces  on  either  side  of 
the  extensor  tendons  are  broadening  out  on  the  back  of  the  hand,  later 


PLATE  V 


Fig.  1. — Cross-section  No.  I. — DSAS,  dorsal  subaponeurotic  space;  DV  and  iV, 
digital  vessels  and  nerves;  ECT,  extensor  communis  tendon;  FT,  flexor  tendon;  PP, 
proximal  phalanx;  SCS,  subcutaneous   space;  SS,  synovial  sheath.      (Kanavel.) 


jDSAb  IM  EPP 


FT        DV—N      LM 


Fig.  2. — Cross-section  No.  II. — Through  epiphysis  of  proximal  phalanx.  DSAS, 
dorsal  subaponeurotic  'space;  DSCS,  dorsal  subcutaneous  space;  DV  and  N,  digital 
vessels  and  nerves;  ECT,  extensor  communis  tendon;  EPP,  epiphysis  proximal  phalanx; 
FT,  flexor  tendon;  IM,  interossei  muscles;  LM,  lumbrical  muscle;  SS,  synovial  sheath. 
(Kanavel.) 


PLATE    VI 


EOT  X>SCd 


DSA'b  MB 


DT  SB 


Fig.  1. — Cross-section  No.  III. — Proximal  to  metacarpophalangeal  joint.  DSAS, 
dorsal  subaponeurotic  space;  DSCS,  dorsal  subcutaneous  space;  DT,  dense  fibrous 
tissue;  DV  and  N,  digital  vessels  and  nerves;  ECT,  extensor  communis  tendon;  FT, 
flexor  tendon;  IM,  interossei  muscles;  LAI,  lumbrical  muscle;  MB,  metacarpal  bone; 
SB,  sesamoid  bone;  SS,  synovial  sheath.      (Kanavel.) 


ECT  V  DSAS  DSCS 


DT  D6 


Fig.  2. — Cross-section  No.  TV. — -Two  cm.  proximal  to  joint.  ATP,  adductor  trans- 
versa pollicis;  DB,  digital  branch,  DSAS,  dorsal  subaponeurotic  space;  DSCS,  dorsal 
subcutaneous  space;  DT,  dense  fibrous  tissue;  ECT,  extensor  communis  tendon;  FLP, 
flexor  longus  pollicis  in  its  synovial  sheath;  FT,  flexor  tendon;  IAI,  interossei  muscles; 
LM,  lumbrical  muscle;  M,  metacarpal  bone;  MFC,  middle  flexion  crease;  MPS,  middle 
palmar  space;  RI,  radialis  indicis;  SS,  synovial  sheath;  TS,  thenar  space.  Note  the 
beginning  of  the  middle  palmar  space.      (Kanavel.) 


PLATE    V 


D5C3 


B1M         M 


DSA5         ECT 


T5        ATP  fLP 


Fig.  1. — Cross-section  No.  V. — 3|  cm.  proximal  to  joint.  ATP,  adductor  trans- 
versa pollicis;  DIM,  dorsal  interosseous  membrane;  DSAS,  dorsal  subaponeurotic 
space;  DSCS,  dorsal  subcutaneous  space;  ECT,  extensor  communis  tendon;  FLP, 
flexor  longus  pollicis  in  its  synovial  sheath;  FT,  flexor  tendon;  HM,  hypothenar  muscles 
with  intermuscular  spaces:  IM,  interossei  muscles:  IS,  space  between  adductor  trans- 
versus  and  first  dorsal  interosseous:  IV,  interosseous  vessels  and  nerve;  LM,  lumbrical 
muscle:  M,  metacarpal  bone:  MPS.  middle  palmar  space;  PIM,  palmar  interosseous 
membrane:  RI,  radialis  indicis;  TS,  thenar  space:  UB,  ulnar  bursa:  UV  and  .V.  ulnar 
vessels  and  nerve;  V,  vein.      (Kanavelj 


Fig.  2. — Cross-section  Xo.  VI. — Through  distal  part  of  thenar  area.  ATP,  adduc- 
tor transversus  pollicis:  DIA.  dorsalis  indicis  artery;  DP  A.  deep  palmar  arch — digital 
branches  beginning;  DSAS,  dorsal  subaponeurotic  space;  DSCS,  dorsal  subcutaneous 
space;  ECT,  extensor  communis  tendon;  FLP,  flexor  longus  pollicis  in  its  synovial 
sheath;  HM,  hypothenar  muscles  with  intermuscular  spaces;  IM,  interossei  muscles; 
ITS,  indefinite  thenar  spaces;  IS,  space  between  adductor  transversus  and  first  dorsal 
interosseous:  LM,  lumbrical  muscle:  MA  and  N,  median  artery  and  nerve:  M,  meta- 
carpal bone:  MPS,  middle  palmar  space;  PF,  palmar  fascia:  PIM,  palmar  interosseous 
membrane;  7*.S-,  thenar  space;  TM,  thenar  muscles;  TMF.  tendon  of  middle  finger; 
UV  and  -V.  ulnar  vessels  and  nerves.      (Kanavel.t 


PLA  lb    VIII 


UB  FT 


Fig.  1. — Cross-section  No.  VII. — DSAS,  dorsal  subaponeurotic  space;  DSi  S 
dorsal  subcutaneous  space:  ECT.  extensor  communis  tendon;  FLP,  flexor  longus 
pollicis  in  ita  synovial  sheath;  FT,  flexor  tendon:  MM,  hypothenar  muscles  with 
intermuscular  spaces;  IS,  space  between  adductor  transversus  and  first  dorsal  interos- 
seous: M,  metacarpal  bone;  MX  and  T",  median  nerve  and  vessels;  MPS.  middle  palmar 
space;  RA,  radial  artery;  SS,  synovial  sheath:  TM.  thenar  muscles:  TS,  thenar  space; 
UB,  ulnar  bursa;   UV  and  .V,  ulnar  vessels  and  nerve.      (Kanavel.) 


DbCS  ECRB 


ecu 


iPTP 


Fig.  2. — Cross-section  Xo.  VIII. — DSCS,  dorsal  subcutaneous  space;  EC,  extensor 
communis;  ECRB,  extensor  carpi  radialis  brevior;  ECRL,  extensor  carpi  radialis 
longior;  ECU,  extensor  carpi  ulnaris;  EMD,  extensor  minimi  digiti;  EPTP,  extensor 
primi  internodii  pollicis;  ESIP,  extensor  secundi  internodii  pollicis;  FLP,  flexor 
longus  pollicis  in  its  synovial  sheath;  HM,  hypothenar  muscles  with  intermuscular 
spaces;  MX  and  V,  median  nerve  and  vessels;  PL,  palmaris  longus;  PMPS,  prolonga- 
tion of  middle  palmar  space;  RV  and  N,  radial  vessels  and  nerves;  SS,  synovial 
sheaths;  TM,  thenar  muscles;  UB,  ulnar  bursa;  UV  and  N,  ulnar  vessels  and  nerve. 
(Kanavel.) 


DISEASES  OF  THE  SKIN  217 

to  become  fused.  The  lumbrical  muscles  are  approximating  the  ten- 
dons from  which  they  have  origin.  The  distal  margin  of  the  adductor 
transversus  pollicis  muscle  is  shown.  The  level  of  the  section  repre- 
sented by  this  diagram  corresponds  to  an  imaginary  line  drawn  from 
the  proximal  end  of  the  distal  flexion  crease  of  the  palm  to  the  distal 
end  of  the  mid-flexion  crease.  This  landmark  represents  the  distal 
boundary  of  two  fascial  spaces  that  are  of  great  importance  in  the 
surgery  of  the  hand.  They  are  situated  just  behind  the  flexor  tendons 
and  in  front  of  the  interossei  and  adductor  muscles  of  the  thumb. 
They  are  separated  from  one  another  mesially  along  the  metacarpal 
bone  of  the  middle  finger  from  which  the  adductor  transversus  muscle 
takes  origin.  The  mid-palmar  space  is  on  the  ulnar  side  and  the  thenar 
space  is  on  the  radial  side.  One  of  the  most  important  facts  to 
remember  about  these  spaces  is  their  close  relation  to  the  lumbrical 
muscles  and  the  branches  of  the  digital  vessels.  As  will  be  seen  later, 
not  only  do  these  spaces  become  infected  along  these  lumbrical  muscles, 
but  the  lumbrical  muscles  are  a  guide  for  drainage. 

Plate  VII,  Fig.  1,  shows  the  fusion  of  the  dorsal  subcutaneous  space 
as  well  as  the  dorsal  subaponeurotic.  The  flexor  tendons  no  longer  are 
invested  by  synovial  sheaths,  with  the  exception  of  the  tendon  to  the 
little  finger  and  the  flexor  longus  pollicis.  The  lumbrical  muscles 
taking  origin  from  the  flexor  profundus  tendons  lie  close  to  the  niid- 
palmar  and  thenar  spaces  that  now  have  extended  laterally  so  as  to 
cover  most  of  the  breadth  of  the  hand.  The  space  between  the 
adductor  transversus  and  the  first  dorsal  interosseous  is  a  third  fascial 
space  in  which  abscesses,  sometimes  communicating  with  the  thenar 
space,  sometimes  not,  are  frequent.  It  will  be  later  seen  how  simple  it 
is  to  drain  both  of  these  spaces,  if  necessary,  through  the  same  incision 
(Fig.  114). 

Plate  VII,  Fig.  2,  shows  the  extensor  tendons  still  without  synovial 
investment,  the  deep  palmar  arch  penetrating  the  hand  as  the  ulnar 
artery  through  the  cleft  between  the  adductor  transversus  and 
adductor  obliquus  muscles  to  the  space  between  the  adductor  trans- 
versus and  the  first  dorsal  interosseous,  then  to  join  the  radial  artery 
as  it  penetrates  between  the  two  heads  of  origin  of  the  first  dorsal 
interosseous.  Through  this  cleft,  and  probably  along  the  route  of 
this  vessel,  infection  may  extend  from  a  thenar  space  abscess  to  the 
space  between  the  thumb  adductors  and  the  first  dorsal  interosseous. 
At  approximately  this  level  originate  the  two  exceedingly  important 
synovial  bursas,  known  as  the  ulnar  and  radial  bursa?.  In  the  normal 
arrangement  of  the  digital  synovial  sheaths  of  the  little  finger  and 
thumb  there  is  a  constriction  that  in  about  one-third  of  the  cases  is 
complete,  but  in  two-thirds  is  partial,  just  proximal  to  the  metacarpo- 
phalangeal joint  (Figs.  109-111).  Proximal  to  these  constrictions  are 
the  ulnar  and  radial  bursa?.  The  tendons  are  projected  into  the 
ulnar  bursa  from  the  radial  side,  and,  as  described  by  Poirier,  often 
divide  the  bursa  into   three   compartments.      Passing   beneath   the 


218 


INJURIES  AND  DISEASES  OF   THE  SKIN 


annular  Ligament,  the  upper  margin  of  which  corresponds  to  the  level  of 
the  distal  flexion  crease  at  the  wrist,  it  extends  anterior  to  the  pronator 
quadratus  muscle  for  a  distance  of  about  3  cm.  The  radial  bursa 
investing  the  tendon  of  the  flexor  longus  pollicis  between  the  adductor 
obliquus  and  the  flexor  brevis  pollicis  extends  beneath  the  branches 
of  the  median  nerve  to  the  thenar  muscles  just  distal  to  the  lower 
margin  of  the  annular  ligament,  then  runs  beneath  the  annular  liga- 
ment in  the  >ame  plane  with  the  ulnar  bursa  and  to  about  the  same 


Fig.  109. — The  fetal  type.     (Poirier.) 

level.  These  bursa3  communicate,  as  a  rule,  about  the  lower  level  of 
the  annular  ligament.  The  arrangement  of  the  synovial  sheaths  to 
the  flexor  tendons  of  the  index  and  middle  fingers  may  vary  and  indi- 
vidual so-called  accessory  sheaths  (Figs.  110  and  111)  may  be  present, 
which,  however,  are  so  close  to  the  ulnar  and  radial  bursae  that  by 
either  direct  communication  or  by  contiguity  infections  from  one 
bursa  generally  spread  very  rapidly  to  the  other. 

Plate  VIII,  Fig.  1,  shows  the  extensor  minimi  digiti  in  a  synovial 
sheath.     The  mid-palmar  and  thenar  spaces  are  narrowed  and  close 


DISEASES  OF  THE  SKIN 


219 


together  beneath  the  tendons.  The  flexor  longus  pollieis  is  in  the 
radial  bursa.  The  flexor  tendons  are  in  the  ulnar  bursa,  with  the 
median  vessels  and  nerves  just  beneath  the  annular  ligament.  The 
radial  artery  from  the  back  of  the  hand  is  passing  between  the  two 
heads  of  the  first  dorsal  interosseous. 

Plate  VIII,  Fig.  2,  shows  all  the  extensor  tendons  in  their  synovial 
sheaths,  the  thenar  and  mid-palmar  spaces  in  close  contiguity  and  the 
flexor  longus  pollieis  in  closer  relation  to  the  accessory  sheaths  and 
ulnar  bursa  investing  the  other  flexor  tendons. 


Fig.  110. — A  normal  adult  type.     (Poirier.) 


In  the  tendon  sheaths  of  the  fingers  it  is  important  to  recognize 
that  there  are  certain  places  much  more  exposed  to  injury  and 
infection  than  others.  Over  the  interphalangeal  joints  the  dense 
transverse  fibres,  corresponding  to  the  deep  layers  of  the  palmar 
fascia  prolongations,  which  may  be  termed  the  phalangeal  annular 
ligaments,  but  which  technically  are  termed  in  textbooks  ligamenta 
vaginalia,  are  absent,  and  the  anterior  surfaces  of  the  sheaths  are 


220 


INJURIES  AND  DISEASES  OF  THE  SKIN 


much  closer  to  the  skin  and  more  unprotected  than  over  the  shafts. 
Accordingly,  penetrating  wounds  of  the  fingers  at  this  point  much 
more  readily  infect  the  sheaths  than  elsewhere. 

Abscesses  developing  over  the  thenar  or  hypothenar  eminences 
may  or  may  not  extend  beneath  the  deep  fascia.  They  do  not  involve 
complicated  or  particularly  important  tissues  and  are  localized  and 
treated  as  similar  abscesses  in  any  other  part  of  the  body.     Sub- 


Fig.  111. — A  very  frequent  adult  type.     (Poirier.) 

cutaneous  abscesses  on  the  dorsum  of  the  hand  are  more  frequently 
found  on  the  ulnar  side,  due  to  the  fact  that  this  side  of  the  back  of 
the  hand  is  more  frequently  exposed  to  friction  trauma. 

Relation  of  the  Digital  Tendon  Sheath  Infections  to  the  Thenar  and 
Mid-palmar  Spaces.— The  lumbricals  are  inserted  on  the  radial  side 
of  the  extensor  tendons.  Accordingly,  infections  travelling  along  the 
lumbrical  muscles  to  the  little  and  ring  fingers  generally  extend  into 


DISEASES  OF  THE  SKIN  221 

the  mid-palmar  space.  Those  that  occur  in  the  canals  to  the  middle 
and  forefingers  extend  to  the  thenar  space.  In  digital  tendon  sheath 
infections,  extensions  of  infection  from  the  little  and  ring  finger  are 
into  the  mid-palmar  space;  from  the  thumb  and  forefinger  into  the 
thenar  space;  from  the  middle  finger  more  frequently  into  the  mid- 
palmar  space,  occasionally  into  the  thenar  space,  sometimes  into  both 
spaces.  Extensions  of  infection  of  the  ulnar  bursa  below  the  wrist  are 
into  the  mid-palmar  space,  from  the  radial  bursa  below  the  wrist  into 
the  thenar  space. 

Extensions  of  Infection  from  the  Ulnar  and  Radial  Bursae  and  the 
Fascial  Spaces  above  the  Annular  Ligament. — Between  the  radial  and 
ulnar  bursae  and  the  tendons  they  invest  above  the  wrist-joint  and 
the  pronator  quadratus  muscle  is  a  potential  space  corresponding 
in  its  fascial  planes  with  the  mid-palmar  and  thenar  spaces  of  the 
palm.  Beneath  the  annular  ligament  these  two  palmar  fascial  spaces 
either  directly  communicate  or  are  in  such  close  contiguity  that  an 
extension  of  infection  from  one  may  occur  in  the  other.  Should  the 
process  go  further  up  the  arm  it  will  extend  to  the  potential  space 
in  front  of  the  pronator  quadratus  muscle,  thence  extending  along  the 
deep  intermuscular  planes,  generally  close  to  the  ulnar  artery  and 
veins.  Less  often  it  may  extend  along  the  radial  vessels.  Should  an 
infection  of  the  radial  or  ulnar  bursae  extend  above  the  annular  liga- 
ment it  may  secondarily  extend  to  this  same  potential  space  in 
front  of  the  pronator  quadratus.  It  is  important  to  know  when  the 
infection  occupies  this  space,  inasmuch  as  drainage  from  the  side  just 
in  front  of  either  the  radius  or  ulna  and  the  pronator  quadratus, 
behind  the  radial  or  ulnar  vessels  and  the  tendons  of  the  hand,  can  be 
established  without  injury  to  the  flexor  tendons  and  their  sheaths. 

Secondary  Extensions  of  Tendon  Sheath  Infections. — By  studying 
Plate  IV,  or  the  drawings  in  Dr.  Kanavel's  book,  the  usual  extensions 
occurring  in  tenosynovitis  are  evident.  The  proximity  of  the  tendon 
sheaths  to  the  proximal  end  of  the  middle  phalanx  and  the  blood- 
vessels supplying  the  bone,  as  can  be  seen  in  sections,  give  a  probable 
reason  why  an  infection  of  this  phalanx  is  so  much  more  common 
than  infections  of  the  bone  elsewhere. 

Extensor  Tendon  Sheaths. — It  is  extraordinary  how  frequently  one 
hears  of  reference  to  the  extensor  tendon  sheaths  on  the  back  of  the 
fingers.  There  are  none.  The  extensor  tendons  are  invested  with 
synovial  sheaths,  beneath  the  dorsal  annual  ligament,  and  for  a  short 
distance  distal  to  it.  The  sheath  of  the  extensor  minimi  digiti 
tendons  extends  further  distal ly  than  the  others  and  has  been  seen 
to  extend  almost  to  the  head  of  the  fifth  metacarpal.  Suppurative 
infections  of  these  sheaths  are  comparatively  rare  and  are  generally 
due  to  an  infected  wound  or  extension  from  a  neighboring  abscess. 
Chronic  infection  of  these  sheaths  due  to  tuberculosis,  or  not  infre- 
quently from  some  other  type  of  infection  the  nature  of  which  it  is 
not  easy  to  ascertain,  are  much  more  common. 


222  INJURIES  AND  DISEASES  OF  THE  SKIN 

Diagnosis  of  Infections  of  Fascial  Spaces  and  Tendon  Sheaths. — It 
is  only  by  constantly  examining  hand  infections  as  seen  in  an  out- 
patient clinic  that  the  shades  of  difference  in  tenderness  and  its  location, 
and  the  interpretation  of  the  value  of  the  different  diagnostic  signs, 
that  skill  in  diagnosis  of  hand  infections  can  be  obtained.  Of  vast 
importance  is  an  accurate  knowledge  of  the  anatomy  of  the  various 
structures.  There  are  certain  fundamental  signs  that  are  of  great 
assistance,  however,  but  it  cannot  be  too  strongly  impressed  on  the 
minds  of  students,  or  those  inexperienced  in  this  type  of  surgery, 
that  the  compact  arrangement  of  so  many  different  kinds  of  important 
tissues,  all  beneath  a  very  dense  covering  of  epidermis,  make  accurate 
diagnosis,  even  with  prolonged  experience,  exceedingly  difficult. 

Tenosynovitis. — By  far  the  most  important  sign  is  tenderness 
sharply  defined  to  the  anatomical  limits  of  the  suspected  sheath.  This 
tenderness  is  often  so  localized  that  with  the  finger  over  the  same  area 
of  skin,  pressure  in  one  direction  may  be  comparatively  painless  and 
pressure  in  the  opposite  direction  may  cause  exquisite  pain.  In  early 
cases  pressure  on  the  sides  of  the  phalanx  may  be  painless,  but  pressure 
just  in  front  of  the  bone,  exerted  by  grasping  the  anterior  closed  space 
between  two  fingers  close  to  the  bone,  may  cause  great  pain.  This 
may  aid  in  differentiating  it  from  cellulitis.  In  the  web  abscesses 
of  the  palm  there  may  be  tenderness  over  the  sheath  in  the  palm,  and 
even  over  the  proximal  phalanx,  due  to  the  associated  cellulitis,  but 
absence  of  tenderness  over  the  sheath  at  the  second  phalanx  may 
greatly  aid  in  excluding  a  sheath  infection.  In  infections  of  the  radial 
and  ulnar  bursa?  they  are  frequently  associated,  and  tenderness  over  the 
sheath  of  the  little  finger  and  thumb  at  the  same  time,  even  though 
the  degree  of  tenderness  in  the  palm  may  be  questionable,  is  almost 
pathognomonic.  In  these  cases  tenderness  over  the  annular  ligament 
may  be  slight  but  marked  just  above  it  when  the  infection  has  extended 
into  the  forearm. 

Active  and  Passive  Limitation  of  Extension  of  the  Finger. — This  sign 
implies  flexion  of  the  fingers.  It  is  important  in  making  the  passive 
extension  test  to  very  gently  extend  the  finger  as  far  as  possible  without 
pain,  holding  it  between  two  fingers  of  the  left  hand  at  the  sides  of  the 
second  phalanges.  By  then  bringing  the  terminal  phalanx  to  full 
extension  with  the  other  hand,  and  thus  putting  the  flexor  profundus 
tendon  of  that  finger  on  the  stretch  without  moving  the  other  structures 
of  the  finger,  passive  extension  may  give  valuable  evidence  in  confirm- 
ing a  sheath  diagnosis.  The  customary  way  of  extending  the  whole 
finger  causes  pain  in  many  other  types  of  finger  infections  that  do  not 
involve  the  sheath,  owing  to  the  traction  exerted  on  the  inflamed 
tissues. 

It  should  be  remembered  that  the  range  of  motion  of  the  tendons 
at  the  proximal  end  of  the  digital  sheaths  is  greater  than  in  the  finger, 
where  their  insertions  are  placed.  Accordingly,  the  preputial  folds 
which  show  so  markedly  at  the  proximal  limits  of  the  digital  sheaths 


DISEASES  OF  THE  SKIN  223 

indicate  that  point  where  the  cavity  of  the  tendon  sheath  is  greatest. 
It  is  a  clinical  fact  that  in  incising  a  sheath  that  contains  pus,  by  far 
the  greatest  amount  is  found  over  the  metacarpophalangeal  joint. 
It  is  also  true  that  the  signs  of  tenderness  on  pressure  and  pain  on 
extension  are  chiefly  referred  to  this  point.  These  two  signs  combined 
with  the  history  of  the  case  which  may  give  some  indication  as  to  the 
probability  of  the  sheath  being  involved,  are  the  main  points  to  be 
relied  upon  for  diagnosis.  If  the  anatomical  structures  contiguous 
to  the  sheaths  are  already  understood,  the  probabilities  of  infection 
by  extension  can  also  be  intelligently  considered.  Swelling  is  of  prac- 
tically no  value  in  early  diagnosis,  nor  do  the  general  symptoms  play 
an  important  role. 

Treatment. — The  only  treatment  for  an  acute  suppurative  tenosyno- 
vitis as  soon  as  the  diagnosis  is  made  is  immediate  operation.  It  is 
in  those  cases  that  may  have  had  an  injury  of  perhaps  a  few  hours  and 
present  themselves  with  moderate  tenderness  limited  to  the  sheath 
area  and  with  beginning  pain  on  extension,  in  which  surgical  judgment 
is  difficult.  Many  do  get  well  by  placing  the  whole  hand  absolutely 
at  rest  in  a  moulded  plaster  of  Paris  or  simple  basswood  splint  after 
thorough  cleaning  of  the  wound  and  surrounding  areas,  with  rest  in 
bed,  catharsis  and  hot  applications.  Such  a  case  should  be  carefully 
watched  and  unnecessary  pressure  over  the  sheath,  for  instance,  by 
having  all  the  members  of  the  house  staff  and  a  large  group  of  students 
elicit  local  tenderness,  should  be  avoided.  It  is  always  risky  post- 
poning operative  procedures  with  these  signs.  Should  there  be  nothing 
more  than  sero-pus  in  the  sheath  at  operation,  there  is  no  reason  why 
perfect  function  should  not  be  regained.  Accordingly,  it  is  wiser,  if 
there  are  distinct  local  signs,  to  give  the  patient  the  benefit  of  the  doubt, 
and  operate.  It  is  only  by  doing  so  early  that  a  stiff  finger  can  be 
avoided.  Unless  there  is  necrosis  of  tendon,  the  function,  in  the 
infections  of  the  radial  and  ulnar  bursa?  is,  as  a  rule,  preserved.  On 
the  other  hand,  infections  of  the  digital  sheaths  are  quite  different, 
and  preservation  of  function  is  much  rarer,  in  fact,  it  is  not  preserved 
as  a  rule.  This  is  chiefly  because  the  patients  are  seen  rather  late  in 
their  course,  after  the  nutrition  to  the  tendons  has  been  cut  off,  so  that 
necrosis  has  begun  and  dense  adhesions  with  obliteration  of  the 
synovial  cavity  are  practically  inevitable. 

Operative  Procedure. — There  should  be  good  light,  a  tourniquet,  and 
in  practically  all  cases,  general  anesthesia.  A  tourniquet  can  be  made 
from  an  arm  band  used  in  one  of  the  various  types  of  blood-pressure 
apparatus.  Small  retractors  should  be  used  and  the  incisions  placed 
with  a  view  toward  preventing  subsequent  contractures.  On  the 
fingers  the  skin  incisions  should  be  between  the  flexion  creases.  They 
should  be  just  to  one  side  of  the  median  line.  They  should  not  be  at 
the  extreme  side  nor  should  they  be  in  the  median  line.  The  advantage 
of  placing  the  incision  at  this  point  can  readily  be  seen  when  the 
position  of  the  digital  vessels  is  noted.      The  branches  from  these 


224  INJURIES  AND  DISEASES  OF  THE  SKIN 

vessels  to  the  sheaths  run  close  to  the  bone  and  enter  the  sheath  from 
its  dorsal  aspect.  An  incision  from  the  side  being  carried  dorsally 
to  the  vessels  would  cut  these  branches.  If  carried  anterior  to  the 
vessels  would  submit  the  main  trunks  to  the  chance  of  pressure  necrosis. 
The  incision  of  the  sheath  should  therefore  be  at  its  anterolateral 
aspect,  and  the  most  direct  course  to  it  is  through  the  incision  in 
the  skin  as  specified  (Fig.  112).  The  greatest  care  and  a  small 
delicate  instrument  should  be  used  in  incising  the  sheath  so  as  not  to 

Fig.  112  Fig.  113 


Figs.  112  and  113. — Photographs  showing  the  postoperative  functional  result  of  an 
acute  suppurative  tenosynovitis  of  the  ring  finger  about  three  weeks  after  the  operation. 
The  location  of  the  skin  incisions  are  here  shown.  Cross  nick  in  flexion  crease  giving 
freer  drainage  by  marked  relief  of  skin  tension.  It  leaves  no  visible  scar.  See  scars  on 
ring  finger,  where  this  was  done.  The  incisions  for  infections  of  the  radial  and  ulnar 
bursa?  below  the  wrist  are  also  shown. 

touch,  if  possible,  the  tendon  and  its  own  "visceral"  synovial  invest- 
ment. By  not  incising  in  the  midline,  the  obliteration  of  dead  space 
is  easier  after  drainage  has  been  sufficient,  and  the  gaping  of  the  wound 
is  distinctly  less.  Much  has  been  written  about  the  skin  incisions. 
The  method  of  incising  the  sheath  is  of  just  as  much  importance,  if 
not  more.  In  the  fingers  the  annular  ligaments  binding  the  tendons 
to  the  phalanges  should  be  cut  for  almost  their  whole  extent.  The 
proximal  portions  of  these  ligaments  if  left  uncut,  even  though  it  be 


DISEASES  OE  THE  SKIN  225 

for  a  distance  of  two  or  three  mm.,  will  not  interfere  with  drainage, 
and  yet  serve  to  prevent  the  tendon  prolapse.  It  should  be  remem- 
bered that  the  middle  flexion  crease  is  directly  over  the  adjacent 
interphalangeal  joint  with  the  finger  flexed  but  slightly  distal  to  it 
on  extension.  Accordingly,  in  incising  a  digital  sheath  of  the  middle 
finger,  for  instance,  one  would  open  the  sheath  near  the  distal  inter- 
phalangeal  joint,  where  its  coverings  are  slight,  and  extend  along  the 
phalangeal  annular  ligament  almost  to  the  proximal  interphalangeal 
joint;  then  through  the  incision  in  the  proximal  closed  space,  the 
unprotected  portion  of  the  sheath  at  the  proximal  interphalangeal 
joint  should  be  incised  and  the  phalangeal  annular  ligament  to  the 
full  extent  of  the  proximal  closed  space.  This  will  leave  its  proximal 
portion,  which  is  in  the  palm,  intact.  Through  an  incision  in  the  palm 
directly  over  the  sheath  and  through  the  transverse  metacarpal 
ligament  the  sheath  should  be  opened  all  the  way  to  its  proximal 
extremity  through  an  adequate  incision.  Many  things  are  used  for 
drainage,  some  of  them  are  gutta-percha  tissue,  rubber  sheeting, 
such  as  a  piece  cut  from  a  surgical  rubber  glove,  gauze,  or  a  bit  of 
folded  thin  China  silk  soaked  in  vaselin  or  alboline  or  camphor- 
carbolic-alcohol  solution  (see  above);  a  cellulose  tissue  capable  of 
boiling,  known  as  "Flexoid,"  which  is  very  soft  and  pliable,  recom- 
mended by  Dr.  Donald  Gordon  of  New  York,  and  in  many  ways 
an  excellent  substitute  for  a  gutta-percha  tissue,  etc.  Whatever 
is  used  should  be  applied  with  the  following  precautions:  Drainage 
should  be  to  the  opening  in  the  sheath  and  not  pressing  in  any 
way  so  as  to  cause  necrosis,  but  not  into  the  sheath.  It  should 
not  protrude  above  the  level  of  the  skin,  but  to  it,  so  that  there  will  be 
no  pressure  of  the  dressing  on  the  drain  itself.  Rubber  tubing  should 
be  condemned.  Drainage  should  be  left  in  place  between  thirty-six 
and  forty-eight  hours.  The  replacement  of  drainage  will  depend 
on  the  type  of  infection.  In  early  cases  where  there  has  been  prac- 
tically no  necrosis  of  tissue  and  gross  slough  is  absent,  drainage  can  be 
omitted.  In  cases  where  necrosis  has  occurred  or  is  inevitable,  drainage 
should  be  replaced,  but  with  the  greatest  care,  so  as  to  hold  open  the 
wall  of  the  sinus  but  not  to  press  in  any  way  upon  the  tendon  or  its 
sheath.  The  accurate  placement  of  drainage  and  its  rapid  removal 
are  most  to  be  desired.  In  short,  the  governing  principle  should  be 
to  establish  drainage  so  as  not  only  to  give  an  exit  for  exudate  but  to 
preserve — and  this  is  most  important — the  blood  supply  and  nutrition 
of  the  tendon  and  its  sheath.  The  incisions  for  drainage  of  the  radial 
and  ulnar  bursse  are  shown  on  the  diagram  (Fig.  112),  and  care  in 
draining  the  radial  bursa  in  the  palm  should  be  taken  not  to  cut  the 
median  nerve  branches  to  the  outer  thenar  muscles  that  cross  the 
line  of  incision  at  the  lower  margin  of  the  annular  ligament.  These 
can  readily  be  seen.  Should  an  adherent  flexor  longus  pollicis  tendon 
result  in  a  stiff  thumb  the  functional  result,  though  not  perfect,  is 
good.  Should  the  external  thenar  muscles  be  paralyzed,  adduction  will 
15 


226 


INJURIES  AND  DISEASES  OF  THE  SKIN 


occur  to  a  greater  or  less  extent,  and  the  functional  result  be  unneces- 
sarily impaired. 

As  regards  the  incision  of  the  annular  ligament  in  severe  cases,  it  has 
been  done  repeatedly  without  serious  results.  On  the  other  hand,  just 
as  in  the  phalangeal  annular  ligaments,  a  few  strands  of  its  proximal 
portion  may  well  be  left  intact  to  prevent  subsequent  tendon  prolapse 
without  interfering  with  drainage.  Should  there  be  an  extension 
from  the  radial  and  ulnar  brusae  to  the  potential  space  in  front  of  the 
pronator  quadratus  muscle,  the  incision  should  be  on  the  side  of  the 
forearm,  as  already  indicated.  The  whole  hand  should  be  placed  in  a 
comfortable  position  on  a  splint  outside  of  a  sterile  towel  that  has  been 
wrapped  round  the  dressing.     Measures  should  be  taken  to  prevent 


«   #• 


Fig.  114. — Photograph  of  the  thenar  swelling  in  an  early  abscess  of  the  thenar 
space.  The  line  of  incision  for  drainage  of  the  thenar  space,  or  the  space  between  the 
adductor  transversus  and  first  dorsal  interosseous,  is  also  shown. 


retention  of  exudate  due  to  clotting  along  the  drain  or  at  the  skin 
surface.  Normal  salt  solution  of  a  temperature  of  106°  F.  should  be 
dripped  on  the  dressings  inside  the  sterile  towel  for  twenty  minutes 
or  thereabouts  every  two  or  three  hours.  These  drips  can  be  main- 
tained for  the  first  day  or  two  and  their  intervals  lengthened  as 
may  seem  wise.  They  give  great  relief  to  the  patient.  The  external 
dressing  should  be  changed  after  twenty-four  hours  and  if  the  drains 
are  adherent  they  should  be  gently  loosened  at  the  surface.  After 
the  moist  drips  have  been  discontinued,  baking  of  the  whole  part 
in  a  dry  dressing  two  or  three  times  a  day  for  three-quarters  of  an 
hour  with  dry  hot  air  at  a  temperature  between  300°-400°  F.  is  recom- 
mended.    The  greatest  care  in  all  dressings  should  be  taken  to  avoid 


DISEASES  OF  THE  SKIN 


227 


hemorrhage  or  pain.  Both  probably  indicate  unnecessary  insult 
to  the  tissues.  After  the  acute  inflammatory  symptoms  have  dis- 
appeared active  motion  can  be  recommended,  but  passive  motion  only 
in  most  intelligent  hands  and  never  so  as  to  cause  pain. 

Treatment  of   Thenar  and   Mid-palmar  Space  Infections. — The  mid- 
palmar  space  should  be  drained  as  indicated  in  the  diagram  by  incisions 


Fig.  115. — Drawing  from  Kanavel  showing  methods  of  draining  the  mid-palmar 
space  along  the  lumbrical  canals  of  the  little  or  ring  fingers,  and  the  thenar  space  in 
the  web  between  the  thumb  and  index  finger,  just  in  front  of  the  adductor  transversus 
muscle.    Observe  that  in  this  manner  drainage  is  between  or  behind  the  tendons. 


between  the  fingers  along  the  lumbrical  canals,  avoiding  any  trauma 
to  the  tendons.  The  incision  for  draining  the  thenar  space  is  through 
the  web  between  the  thumb  and  index  finger  where  the  free  edge  of 
the  adductor  transversus  muscle  is  readily  exposed  (Fig.  114).  The 
thenar  space  can  then  be  entered  just  anterior  to  it  and  the  space 
between  the  adductor  transversus  and  the  first  dorsal  interosseous 
can  be  entered  directly  posterior  to  it  (Fig.  115). 


228  INJURIES  AND  DISEASES  OF  THE  SKIN 

Erysipeloid  Infection  of  the  Hand. — This  type  of  infection  is  seen 
chiefly  in  fishmen  and  cooks.  It  is  due  to  a  rod-shaped  bacillus 
described  by  Rosenbach.  It  is  a  cellulitis  and  dermatitis.  It  rarely 
forms  pus.  It  rarely  extends  above  the  wrist,  or  to  it.  It  causes 
considerable  swelling,  only  slight  tenderness,  marked  redness  resemb- 
ling erysipelas  in  its  well-defined  border,  but  without  its  constitutional 
symptoms.  The  tissues  are  tense  but  limitation  of  motion  is  slight. 
It  is  often  unrecognized  and  operated  on  unnecessarily.  Its  treatment 
is  immobilization  and  dressing,  preferably  with  20  per  cent,  ichthyol 
ointment.     Recovery  often  takes  from  ten  days  to  two  weeks. 

Clavus,  or  Corn. — Corns  are  conical  epidermal  hypertrophies 
occurring  on  the  feet,  at  points  pressed  upon  by  ill-fitting  shoes. 
When  situated  on  the  dorsal  or  plantar  surface  of  a  toe  they  are  dry 
and  hard;  when  between  the  toes  they  are  softened  by  the  perspiration. 
Both  varieties  are  painful  and  at  times  disabling. 

Treatment. — The  prophylactic  treatment  consists  in  wearing  hygienic 
shoes  which  are  so  constructed  as  to  avoid  undue  pressure  at  any  point. 
Corns  may  be  removed  by  daily  touching  them  with  a  mixture  of 
salicylic  acid  and  collodion,  60  grains  to  the  ounce,  and  afterward 
peeling  off  the  collodion  cap  with  as  much  of  the  softened  callus  as 
will  easily  come  away.  Removal  with  the  knife  after  soaking  in 
hot  water  is  quicker,  and  if  skilfully  done  can  be  accomplished  without 
bleeding  or  wounding  the  healthy  skin.  Soft  corns  should  be  treated 
with  aristol  or  some  other  drying  powder  applied  on  cotton  or  gauze 
placed  between  the  toes  to  absorb  the  moisture. 

Rare  Forms  of  Chronic  Infection  of  the  Skin. — Actinomycosis, 
blastomycosis,  and  syphilis  exhibit  a  variety  of  cutaneous  lesions. 
The  diseases  are  described  in  Chapter  IV,  but  for  a  description  of  the 
skin  lesions  the  reader  is  referred  to  some  treatise  on  dermatology. 

Mycetoma. — Mycetoma,  or  Madura  foot,  is  a  chronic  infection  begin- 
ning in  the  skin  of  the  foot,  characterized  by  the  formation  of  extensive 
granulomatous  areas  which  slowly  destroy  all  of  the  tissues  of  the  foot 
and  necessitate  amputation  of  the  limb.  It  prevails  in  India  and  other 
tropical  countries,  but  is  rarely  seen  in  the  United  States. 

Frambesia. — Frambesia  or  yaws  is  another  tropical  disease  of  the 
skin  characterized  by  the  formation  of  papular  lesions  chiefly  in  regions 
where  skin  and  mucous  membrane  join.  The  lesions  are  more  or  less 
confluent,  exhibit  a  purulent  discharge,  are  often  covered  with  crusts, 
and  finally  develop  into  a  raw  fungating  bleeding  ulcer,  which  occasion- 
ally heals  spontaneously.  Surgical  removal  by  means  of  the  cautery 
or  curette  is  the  treatment  to  be  recommended. 

Guinea-worm. — This  disease  is  characterized  by  the  formation  of  an 
oval  vesicular  lesion  of  the  skin,  which  is  caused  by  the  presence 
of  the  Filaria  medinensis,  a  long,  slender  worm.  The  disease  is 
acquired  in  the  tropics,  and  in  all  probability  through  drinking-water. 
The  embryos  are  taken  into  the  alimentary  canal,  migrate  to  the 
skin  and  develop  just  beneath  it,  where  they  lie  coiled  up,  and  by  their 


DISEASES  OF  THE  SKIN  229 

presence  give  rise  to  sufficient  local  irritation  to  produce  the  vesicle. 
When  the  lesion  is  fully  developed  the  worm  occasionally  can  be  felt 
through  the  epidermis.  The  lesion  may  be  removed  surgically  or 
the  worm  killed  by  antiseptic  injections. 

Ainhum. — Spontaneous  amputation  of  the  finger  or  toe  by  the 
formation  of  a  cicatricial  ring  or  keloid  formation  which  slowly 
progresses  and  eventually  cuts  off  the  blood  supply  to  the  digit.  It 
occurs  chiefly  in  negroes  who  inhabit  tropical  countries,  and  affects 
by  preference  the  fifth  toe. 

Ulcer. — An  ulcer  is  a  raw  surface  caused  by  a  more  or  less  extensive 
necrosis  of  the  skin  or  mucous  membrane.  On  mucous  surfaces  any 
loss  of  substance  is  spoken  of  as  an  ulcer.  In  the  skin,  necrosis  or 
destruction  of  the  epithelial  layer  only  is  called  an  abrasion  or  excoria- 
tion, the  term  ulcer  being  applied  only  when  the  destructive  process 
has  extended  into  the  corium  or  below  it.  Ulcers  not  infrequently 
involve  the  subcutaneous  cellular  tissues,  muscular  and  fascial  layers. 
An  ulcer  may  be  caused  by  a  destructive  process  which  begins  on  the 
surface  and  progresses  inward,  as  an  ulcer  from  a  burn  or  one  resulting 
from  a  superficial  trauma;  or  it  may  begin  within  or  beneath  the  skin 
and  work  outward,  as  an  abscess,  or  gumma,  which  gradually  extends 
until  the  superficial  layers  are  invaded  and  destroyed. 

An  ulcer  may  be  caused  by  trauma,  by  the  action  of  chemical  or 
thermal  irritants,  by  inflammatory  processes,  by  pressure,  by  interfer- 
ence with  the  circulation  of  a  part,  by  disease  or  interference  with 
the  trophic  centres  or  nerve  fibres,  by  the  sloughing  of  new  growths 
or  one  of  the  infective  granulomata,  and  by  the  inability  to  close 
completely  large  cutaneous  or  mucous  membrane  wounds  occurring 
in  surgical  operations.  With  the  exception  of  aseptic  surgical  wounds, 
practically  all  ulcers  are  infected  with  pyogenic  bacteria.  Most  ulcers 
begin  by  an  area  of  necrosis,  which  may  be  located  superficially  or 
belowr  the  surface.  This  area  may  be  extensive,  as  one  caused  by  a 
burn  or  a  severe  trauma;  or  it  may  be  small,  such  as  is  seen  often  in 
the  minute  central  slough  of  a  syphilitic  lesion  of  the  skin.  Around 
this  necrotic  area  there  will  occur  a  zone  of  hyperemia,  and  later  a 
round-cell  infiltration  of  the  tissues.  As  a  result  of  this  inflammatory 
process  the  slough  is  gradually  separated  and  may  be  cast  off  en  masse 
or  liquefy  and  be  discharged  as  pus.  If  the  original  cause  of  the 
necrosis  is  a  progressive  one,  it  may  extend  peripherally  and  slough 
centrally,  causing  a  gradually  increasing  ulcer,  as  seen  in  the  serpiginous 
syphilides,  rodent  ulcer,  or  the  ulcers  of  tuberculosis.  When  the 
progress  of  an  ulcer  ceases  and  all  sloughs  are  cast  off,  granulations 
appear  on  its  base,  which  grow  rapidly  and  eventually  fill  the  cavity. 
The  granulation  tissue,  at  first  soft  and  vascular,  gradually  becomes 
converted  into  connective  tissue,  the  fibres  of  which  contract  and 
tend  to  draw  the  edges  together.  Cicatrization  occurs  from  the 
growth  inward  of  epithelium  from  the  cutaneous  margins. 

The  clinical  appearances  and  general  behavior  of  the  various  forms 


230  INJURIES  AND  DISEASES  OF  THE  SKIN 

of  ulcer  differ  greatly,  and  have  led  to  a  number  of  rather  elaborate 
and  unsatisfactory  classifications. 

Perhaps  the  most  satisfactory  classification  would  be  that  based 
upon  their  etiology.  We  would  then  have  six  general  classes— those 
due  to  trauma,  to  infections,  to  circulatory  changes,  to  trophic  dis- 
turbances, to  constitutional  diseases,  and  to  new  growths. 

The  traumatic  ulcers  would  include  those  due  to  loss  of  tissue  from 
injury,  from  chemical  or  thermal  agents,  from  electric  currents,  or 
the  z-rays. 

The  infective  ulcers  would  comprise  those  due  to  acute  or  chronic 
infections  of  the  skin  or  mucous  membrane,  as  ulcers  resulting  from 
furuncles,  carbuncles,  cellulitis,  syphilis,  tuberculosis,  actinomycosis, 
blastomycosis,  and  many  other  acute  or  chronic  inflammatory  processes. 

The  circulatory  would  include  those  due  to  a  diminished  blood 
supply,  as  from  arterial  sclerosis,  thrombosis  or  embolism,  pressure 
ischemia,  and  those  due  to  an  impeded  venous  current  from  cardiac 
disease  or  varicose  veins. 

The  trophic  uh-rrs  are  those  due  to  imperfect  nutrition  from  loss  of 
nerve  supply  to  a  part  or  from  some  central  nervous  lesion.  Nerve 
section  or  neuritis,  locomotor  ataxia,  and  syringomyelia  are  the 
commonest  etiologic  factors  in  this  class. 

Of  the  constitutional  diseases  which  give  rise  to  ulcer  may  be  men- 
tioned scurvy,  diabetes,  the  various  forms  of  nephritis,  typhoid  fever, 
and  other  debilitating  conditions. 

The  ulcers  due  to  new  growth  are  the  epithelioma  and  the  secondary 
ulcers  due  to  necrosis  of  deep-seated  carcinomata  or  sarcomata. 

In  all  of  these  classes  certain  clinical  types  of  ulcer  appear,  some  of 
which  it  is  well  to  recognize. 

Healing  Ulcer. — When  the  process  of  repair  is  well  under  way, 
practically  all  ulcers  look  alike.  The  loss  of  substance  is  replaced 
by  a  bright-red  mass  of  granulations,  which  is  covered  with  a  thin 
layer  of  healthy  pus;  the  edges  of  the  ulcer  are  soft  and  thin,  and 
gradually  fade  into  a  bluish  film  which  extends  over  the  marginal 
granulations.     The  surrounding  skin  is  soft  and  healthy. 

Fungating  or  Exuberant  Ulcer. — The  fungating  or  exuberant  ulcer 
is  characterized  by  an  excessive  growth  of  granulations  which  project 
well  above  the  surrounding  skin,  bleed  freely,  and  generally  appear 
pale  or  flabby.  There  is  little  or  no  tendency  to  cicatrization.  Not 
infrequently  this  condition  is  due  to  the  irritation  produced  by  a 
foreign  body  imbedded  in  the  granulations,  as  a  ligature  or  spicule  of 
bone,  or  to  a  persistent  discharge  from  some  septic  focus. 

Inflamed  Ulcer. — The  inflamed  ulcer  appears  red  and  angry.  The 
base  is  necrotic,  the  edges  everted  and  overhanging,  the  surrounding 
skin  congested  and  edematous.  The  entire  region  is  painful  and 
tender  to  pressure.  The  cause  may  be  external  irritation,  impeded 
venous  circulation,  constitutional  causes,  as  gout,  eczema,  etc.,  or 
infection. 


DISEASES  OF  THE  SKIN  231 

Indolent  or  Chronic  Ulcer. — Any  ulcer  may  become  indolent  from 
neglect,  impeded  circulation,  or  constitutional  causes.  These  ulcers 
may  occur  in  any  part  of  the  body,  but  are  most  frequently  seen  on 
the  lower  legs  of  elderly  people  with  varicose  veins  and  edematous 
tissues.  They  appear  as  large  unhealthy-looking  sores,  with  thickened 
purple  margins,  the  central  area  consisting  of  an  irregular  surface  of 
pale  flabby  granulations,  often  showing  exposed  necrotic  shreds  of 
fascia,  muscle,  or  bare  bone.  They  have  a  glazed,  dry  appearance,  and 
the  surrounding  skin  is  thickened,  congested,  edematous,  pigmented, 
and  occasionally  the  seat  of  a  chronic  eczema. 

Spreading,  Phagedenic,  or  Sloughing  Ulcer. — This  resembles  the 
inflamed  ulcer,  but  has  in  addition  a  tendency  to  spread  rapidly.  The 
base  is  usually  necrptic,  the  edges  greatly  undermined,  and  the  sur- 
rounding tissues  deeply  congested.  There  is  usually  an  abundant 
thin,  foul-smelling  discharge.  The  neighboring  lymph  nodes  are 
enlarged  and  there  may  be  considerable  general  sepsis.  The  cause  is 
usually  a  virulent  infection,  a  depraved  constitutional  state  from  disease 
or  dissipation,  or  both  combined. 

Scorbutic  Ulcer. — This  appears  most  frequently  on  mucous  mem- 
branes, but  it  may  occur  also  upon  the  skin.  The  cause  of  the  necrosis 
is  usually  a  blood  clot.  The  destruction  of  tissue  is  often  rapid  and 
extensive,  the  base  of  the  ulcer  is  frequently  black  or  covered  with  a 
fibrinous  exudate,  and  there  is  a  marked  tendency  to  bleed  on  the 
slightest  contact. 

Syphilitic  Ulcer. — A  late  syphilitic  ulcer  is  practically  always  a 
necrosing  gumma.  The  base  is  usually  indurated.  The  surface  is 
generally  covered  with  a  white  slough  at  ■  first,  which  later  becomes 
of  a  dirty  gray  color  and  gradually  separates.  Under  favorable  con- 
ditions after  separation  of  the  slough  the  ulcer  is  gradually  converted 
into  a  healing  ulcer,  which  finally  cicatrizes,  leaving  a  depressed  scar 
covered  with  a  thin  pearly-white  cicatrix  which  is  easily  made  to 
wrinkle  by  pressure  on  the  surrounding  skin.  Under  unfavorable 
conditions  the  peripheral  induration  spreads,  the  central  loss  of  sub- 
stance becomes  larger  and  may  reach  an  enormous  size.  The  shape 
of  the  ulcer  is  generally  round  or  oval. 

Tuberculous  Ulcer. — This  occurs  in  several  forms.  The  tuberculous 
wart,  commonly  seen  in  butchers  and  in  those  who  handle  anatomic 
material,  appears  usually  on  the  back  of  the  fingers  as  an  indolent 
induration  which  finally  ulcerates  and  slowly  spreads  to  the  surrounding 
tissues. 

The  tuberculous  gumma  occurs  as  an  indolent  bluish-red  infiltration 
of  the  skin,  often  in  the  region  of  tuberculous  lymph  nodes.  The 
lump  finally  softens,  a  superficial  slough  forms,  and  the  mass  is  dis- 
charged, leaving  a  necrotic  undermined  ulcer  with  irregular,  corrugated 
edges  surrounded  by  a  purple  or  bluish  infiltration  of  the  skin.  Later 
the  cavity  fills  with  unhealthy  graulations  which  secrete  a  thin, 
watery  pus.     There  is  little  tendency  to  heal. 


232 


IX JURIES  AND  DISEASES  OF   THE  SKIN 


The  most  destructive  form  of  skin  tuberculosis  is  lupus.  While 
this  disease  may  occur  in  any  part  of  the  body,  it  attacks  by  preference 
the  face,  generally  beginning  at  the  junction  of  the  cheek  with  the 
ala  of  the  nose.  It  is  more  frequent  in  women  than  in  men,  and  occurs, 
as  a  rule,  in  the  first  or  second  decade  of  life.  The  disease  begins  by 
the  formation  of  several  small  nodules  in  the  corium,  which  grow 
slowly,  gradually  undergo  necrosis,  and  coalesce.  As  the  process 
first  appears  on  the  surface  of  the  skin,  there  is  a  small  elevated  yellow- 
ish or  brownish  area  surrounded  by  a  number  of  soft  nodules  about  the 
size  of  the  head  of  a  pin.  This  central  area  soon  breaks  down,  leaving 
a  shallow,  indolent  ulcer  which  furnishes  a  small  amount  of  purulent 
secretion,  in  which  tubercle  bacilli  may  be  found.  As  the  process 
extends  the  peripheral  nodules  slowly  undergo  necrosis,  and  new 
nodules  appear  in  the  surrounding  skin.  Crusts  occasionally  form  on 
the  surface  of  the  lesion,  and  in  some  cases  pale  granulations  appear, 
and  eventually  result  in  slow  cicatrization  of  one  part  of  the  ulcer  as 


Fig.  110. — Tuberculosis  of  the  skin. 


it  extends  in  another.  While  the  disease  in  most  instances  is  limited 
to  the  skin  and  subcutaneous  tissue,  it  may  extend  to  muscle,  cartilage, 
and  bone,  causing  extensive  destruction  of  tissue  and  great  deformity. 

Marjolin's  Ulcer. — This  disease  is  an  epitheliomatous  degeneration 
of  a  chronic  ulcer  or  of  irritated  scar  tissue.  It  occurs  in  old  and 
neglected  leg  ulcers,  in  the  ulcers  associated  with  multiple  fistulous 
openings  about  the  perineum  or  ischiorectal  region,  in  chronic  ulcers 
from  irritation  of  the  tongue  or  mucous  membrane  of  the  cheek,  or 
in  any  other  tissue  of  the  body  where  a  chronic  ulcerative  process 
is  subjected  to  constant  irritation  from  any  cause.  The  malig- 
nant change  in  all  probability  arises  from  the  fact  that  certain 
young  epithelial  cells  become  imbedded  in  the  granulation  tissue 
and  form  a  tumor  matrix,  which  later  undergoes  more  or  less  rapid 
proliferation. 

This  change  is  indicated  by  a  hardening  and  elevation  of  the  edges 
of  the  ulcer,  rapid  marginal  infiltration,  a  papillomatous  appearance 


PLATE  IX 


Basal    Cell    Epithelioma  of  Scalp.      (Lumiere  Photograph.) 

Patient  in  the  author's  service  at  the  Roosevelt  Hospital. 


DISEASES  OF  THE  SKIN  233 

of  the  surface,  a  tendency  to  bleed  easily,  and  the  occurrence  of  an 
increased  amount  of  pain. 

Epitheliomatous  Ulcer. — This  occurs  in  two  forms.  The  basal-cell 
epithelioma  or  rodent  ulcer,  which  appears  first  as  a  warty  growth, 
generally  on  the  face.  This  later  ulcerates  and  slowly  spreads  as  a 
round  superficial  ulcer  with  a  smooth,  glossy  base  and  slightly  elevated, 
rounded,  hard  edges.  The  growth  is  exceedingly  slow,  but  it  never 
heals.     It  apparently  never  involves  the  lymphatic  structures,  and  if 


Fig.  117. — Epithelioma  of  the  hand. 

thoroughly  removed  never  returns.  It  occurs  after  middle  life,  and  is 
painless.  The  other  variety  of  epitheliomatous  ulcer  is  the  ordinary 
squamous  cell  epithelioma,  which  occurs  most  frequently  at  the  mucous 
and  cutaneous  margins.  It  also  is  a  disease  of  later  life,  may  occur 
on  skin  or  mucous  membrane,  and  begins  as  a  warty  nodule,  an  abra- 
sion, or,  rarely,  as  a  crack  in  the  mucous  membrane  of  the  lip  which 
shows  no  tendency  to  heal.  The  nodule  soon  ulcerates  and  presents 
hard,  irregular  margins  with  an  angry,  granular  base.  The  growth 
is  at  first  slow,  but  later  becomes  more  rapid  and  is  accompanied  by 


234  INJURIES  AND  DISEASES  OF  THE  SKIN 

pain.  The  lymphatic  structures  are  later  involved,  and  the  disease  is 
of  a  decidedly  malignant  character. 

Secondary  Malignant  Ulcer. — This  is  formed  by  the  breaking  down 
of  carcinomatous  and  sarcomatous  deposits.  They  extend  rapidly, 
cause  extensive  destruction  of  tissue,  and  constitute  one  of  the  most 
distressing  of  the  terminal  symptoms  of  malignant  disease. 

Treatment  of  Ulcers. — In  the  treatment  of  ulcers  the  plan  to  be 
followed  should  be,  if  possible,  to  convert  the  various  forms  of  ulcer 
into  the  simple  healing  variety,  the  treatment  of  which  will  be  outlined 
below.  In  the  case  of  squamous  cell  epithelioma,  or  the  secondary 
ulcers  of  carcinoma  and  sarcoma,  this  never  can  be  accomplished,  and 
the  only  hope  of  cure  is  by  early  and  thorough  removal  of  the  disease 
with  the  adjacent  lymphatic  structures.  In  rodent  ulcer  and  lupus 
complete  excision  is  undoubtedly  the  best  treatment,  and  many 
permanent  cures  are  effected  by  this  method.  The  frequent  location 
of  these  diseases  on  the  face,  however,  will  often  preclude  the  possibility 
of  such  radical  measures,  and  caustic  applications  preceded  by  thorough 
curetting  have  been  followed  by  success  in  the  case  of  rodent  ulcers, 
and  antiseptic  measures  occasionally  have  been  successful  in  lupus. 
The  use  of  the  a>rays,  Finsen  light,  and  radium  in  these  conditions  has 
gradually  replaced  most  of  the  older  methods  of  treatment.  For  the 
treatment  of  rodent  ulcer  the  x-rays  or  radium  is  to  be  recommended, 
for  lupus,  the  Finsen  light  therapy.  In  actinomycosis  and  blastomy- 
cosis the  internal  use  of  potassium  iodide  or  the  copper  salts  has  been 
found  to  be  of  value  in  combination  with  local  antiseptic  applications 
or  the  use  of  radiant  energy. 

Syphilitic  ulcers  should  be  treated  by  mercurial  ointment  locally, 
by  the  administration  of  salvarsan,  and  by  the  internal  use  of  mercury 
and  potassium  iodide,  the  latter  to  be  given  in  progressively  increasing 
doses. 

The  spreading  ulcers,  if  of  septic  origin,  should  be  treated  with 
glutol  or  formalin-gelatin,  or  thoroughly  cauterized  with  pure  nitric 
or  carbolic  acid,  and  afterward  treated  by  a  wet  carbolic  acid  or 
bichloride  dressing.  Inflamed  or  varicose  ulcers  should  be  kept  at 
rest  by  placing  the  patient  in  bed,  and  treated  at  first  by  hot  poultices  or 
a  dressing  of  weak  bichloride  or  carbolic  solution  until  the  chronic- 
passive  congestion  is  relieved,  the  edges  softened  and  more  healthy, 
and  the  sloughs  separated  from  the  floor  of  the  ulcer.  After  this, 
granulation  should  be  stimulated  by  a  wet  dressing  of  myrrh  wash 
(1  part  of  tincture  of  myrrh  to  12  parts  of  water),  red  wash  or  the  use 
of  unguentum  hydrargyri,  half-strength.  In  the  exuberant  ulcer  the 
cause  of  the  overgrowth  should  be  found  and  removed,  after  which  the 
granulations  should  be  cut  down  to  the  level  of  the  surrounding  skin 
with  scissors,  and  silver  nitrate  applied.  If  the  granulations  are  pale 
and  watery,  the  application  for  forty-eight  hours  of  several  layers  of 
gauze  soaked  in  glycerin  will  often  cause  them  to  shrink  from  the 
withdrawal  of  fluid,  and  stimulate  them  to  a  healthy  growth. 


NEW  GROWTHS  OF  THE  SKIN  235 

The  treatment  of  a  healing  nicer  should  consist  chiefly  in  what 
Morris  speaks  of  as  a  "  skilful  neglect" — that  is,  avoiding  measures 
which  retard  repair,  such  as  irritating  dressings  frequently  changed, 
excessive  movement  of  the  part,  and  positions  which  favor  active  or 
passive  congestion.  The  part  should  he  kept  at  rest  in  such  a  position 
as  to  favor  free  circulation,  especially  the  return  of  venous  blood. 
Astringent  wet  dressings,  such  as  myrrh  wash,  black  wash,  or  alumin- 
ium acetate,  are  serviceable;  also  bland  ointments,  as  cold  cream, 
lanolin,  white  vaseline,  or  zinc  oxide  ointment.  Strapping  the  ulcer 
and  surrounding  skin  with  overlapping  strips  of  lead  or  zinc  oxide 
plaster  and  allowing  the  plaster  to  remain  in  place  three  or  four  days, 
or  encasing  the  entire  leg  and  foot,  with  the  exception  of  the  toes, 
with  an  evenly  applied  strapping  of  plaster  often  will  be  followed  by 
rapid  healing.  In  varicose  leg  ulcers  the  use  of  an  elastic  stocking  or 
Martin's  bandage  will  improve  the  circulation  and  favor  cicatrization. 
Protecting  the  granulations  with  gold-beater's  skin  or  silver  foil  is 
to  be  recommended.  Large  ulcers  which  do  not  heal  rapidly  should 
be  subjected  to  skin-grafting. 


NEW  GROWTHS  OF  THE  SKIN. 

Papillomata,  or  Warts. — Warts  are  cutaneous  excrescences  and  con- 
sist of  a  group  of  hypertrophied  papillae  covered  with  epithelium, 
forming  an  oval  or  conical  tumor  which  varies  in  size  from  that  of  a 
pin's  head  to  that  of  an  orange.  They  occur  chiefly  on  the  hands,  on 
the  penis,  and  about  the  female  genital  organs  and  the  anus.  Their 
growth  on  mucous  surfaces  is  favored  by  heat,  moisture,  and  the 
presence  of  irritating  discharges.  From  cutaneous  surfaces  they  should 
be  removed  by  thorough  curetting  and  the  application  of  solid  silver 
nitrate  to  the  resulting  wound.  The  application  of  glacial  acetic  acid 
or  the  use  of  the  x-rays  or  radium  also  has  been  recommended. 
From  mucous  surfaces  they  may  be  simply  removed  with  scissors, 
and  the  wounds  dressed  with  aristol  or  other  antispetic  powders. 

Sebaceous  Cysts. — These  tumors  (Fig.  120)  are  of  fairly  frequent 
occurrence,  especially  on  the  scalp.  They  are  encapsulated  masses 
of  sebaceous  material  due  to  a  retention  of  the  secretion  of  a  sebaceous 
gland.  They  are  round,  painless  swellings  in  the  skin,  and  on  close 
inspection  a  black  comedo  generally  can  be  seen  on  the  summit  of  the 
mass. 

Treatment. — The  treatment  should  be  by  incision  to  the  capsule, 
and  by  enucleation  by  a  probe  or  some  other  blunt  instrument. 

Dermoids. — These  cysts  occur  often  in  the  median  line  of  the  body 
or  over  the  situation  of  the  embryonic  clefts.  The  superficial  variety, 
called  atheromatous  dermoids,  resemble  closely  the  sebaceous  cysts 
in  that  they  contain  a  semisolid,  cheesy  material  made  up  of  the  secre- 
tion of  sebaceous  glands  and  macerated  epithelial  cells.     The  deeper 


236 


INJURIES  AND  DISEASES  OF  THE  SKIN 


Fig.  118. — Sebaceous  cyst  of  the  scalp. 


»-Otftf 


Fig.  119. — Sebaceous  cyst  of  the  scalp. 


NEW  GROWTHS  OF  THE  SKIN  237 

varieties  often  contain  hair,  teeth,  and  other  tissues.     They  will  be 
described  more  at  length  in  other  sections. 

Fibromata. — Fibromata  of  the  skin  are  of  fairly  frequent  occur- 
rence. The  hard  fibromata  are  composed  of  dense  fibrous  tissue, 
which  in  their  growth  cause  a  thickening  of  the  surrounding  tissues 
resembling  a  capsule.  These  not  infrequently  arise  from  the  sheath 
of  a  cutaneous  nerve,  the  painful  subcutaneous  tubercle,  and  give  rise 
to  more  or  less  severe  pain.  The  soft  fibromata  are  made  up  of  areolar 
tissue  and  are  often  pedunculated.  These  frequently  are  multiple, 
develop  along  the  cutaneous  nerve  trunk,  and  constitute  a  condition 
called  fibromata  molluscum.  Fibroneuromata  are  tumors  growing 
from  a  cut  or  injured  nerve,  and  contain  both  fibrous  tissues  and  nerve 
filaments.  Moles  are  fibromata  of  the  skin  which  are  generally 
congenital,  are  pigmented,  and  frequently  present  a  growth  of  hair 
on  their  surface. 


Fig.  120. — Multiple  atheromatous  cysts  (wens).     (Lexer.) 

These  tumors  rarely  give  rise  to  surgical  indications  unless  they 
are  painful  or  produce  deformity,  in  which  case  they  should  be  removed. 
Care  should  be  taken,  however,  to  remove  the  entire  growth,  as  par- 
tial removal,  especially  in  pigmented  moles,  is  occasionally  followed 
by  malignant  degeneration. 

Keloid. — Keloid  is  an  exuberant  cicatrix  caused  by  the  development 
of  an  abnormal  amount  of  fibrous  tissue  in  and  about  the  scar  of  a 
wound  or  burn.  It  appears  gradually  after  the  complete  healing 
of  the  wound,  and  may  continue  to  enlarge  for  several  months.  At 
first  the  tissue  is  highly  vascular  and  has  a  purplish  appearance;  later 
it  becomes  paler  and  more  firm.  It  occurs  with  great  frequency  in  the 
negro  race  (Fig.  121).  Occasionally  these  growths  undergo  sarcomatous 
change. 


238 


INJURIES  AND  DISEASES  OF  THE  SKIN 


Treatment. — Considerable  difference  of  opinion  exists  regarding 
their  treatment.  Some  surgeons  advise  complete  removal  with  careful 
union  of  the  wound,  hoping  for  primary  union  with  a  small  scar. 
Others  advise  non-interference,  for  the  reason  that  the  secondary 
scar  is  liable  to  be  as  large  or  larger  than  the  one  removed,  and  also  for 
the  additional  reason  that  surgical  interference  occasionally  seems  to 
favor  the  development  of  malignant  changes.  The  hypodermic  use 
of  thiosinamine  is  said  to  produce  shrinkage  in  the  keloid  tissue  in 
certain  cases.     The  .r-rays  or  radium  may  be  useful. 


Fig.  121. — Keloid  tumors  of  bark.     (Roberts.) 


Carcinoma. — This  occurs  as  a  primary  growth  in  the  skin,  epithe- 
lioma; as  a  secondary  involvement  from  some  adjacent  organ;  as  a 
degenerative  process  engrafted  on  some  benign  skin  lesion,  as  an  ulcer, 
wart,  or  mole;  or,  very  rarely,  as  a  metastatic  deposit,  which  may  be 
single  or  multiple. 

Epithelioma  has  already  been  considered  earlier  in  the  chapter,  and 
the  general  features  of  carcinoma  have  been  discussed  in  Chapter  IV. 

Sarcoma. — Primary  sarcoma  of  the  skin  is  exceedingly  rare;  sar- 
comatous degeneration  of  a  fibroma  is  more  frequently  observed. 
This  change  occurs  commonly  in  pigmented  moles. 


SKIN-GRAFTING  239 

Secondary  sarcomatous  deposits  in  the  skin  are  not  infrequent. 
If  the  primary  growth  is  a  melanotic  sarcoma,  the  secondary  nodules 
will  contain  pigment. 

Idiopathic  multiple  hemorrhagic  sarcoma  has  been  described,  also 
sarcomatosis  cutis.  These  diseases  are  characterized  by  the  develop- 
ment of  multiple  small  sarcomatous  lesions  over  large  areas  of  the  body. 
In  the  former  condition  the  lesions  are  dark  red  or  purple  in  color  and 
may  resemble  angiomata;  in  the  latter  the  lesions  exhibit  no  pigment 
or  unusual  vascularity. 

In  the  treatment  of  malignant  growths  of  the  skin  the  same  principles 
should  be  followed  as  in  other  tissues. 

Early  radical  removal  constitutes  the  best  treatment,  when  the 
disease  can  be  completely  eradicated.  In  the  various  secondary 
and  metastatic  lesions  this  plan  is  abviously  impracticable,  and 
palliative  measures  are  to  be  recommended.  The  x-rays  or  radium 
will  often  be  of  service  in  these  cases,  and  in  the  sarcomata  the  use  of 
Coley's  fluid  is  to  be  advised. 

Keen  has  recently  emphasized  the  fact,  which  is  not  yet  fully 
appreciated  by  the  profession,  that  warts  and  moles  when  subjected 
to  more  or  less  constant  irritation  are  prone  to  undergo  malignant 
change,  and  should  be  removed  before  malignant  degeneration  has 
occurred. 

When  the  irritated  lesion  is  a  papilloma,  epithelioma  is  produced; 
when  a  mole,  either  carcinomatous  or  sarcomatous  transformation 
may  occur. 

When,  after  a  long  period  of  quiescence,  one  of  these  lesions  begins 
to  grow,  malignant  change  has  probably  occurred  and  demands  prompt 
radical  treatment. 

SKIN-GRAFTING. 

Skin-grafting  is  employed  to  hasten  the  healing  of  large  ulcers 
and  consists  in  removing  portions  of  epidermis  from  the  inner  aspect 
of  the  arm  or  thigh,  and  planting  them  on  the  healthy  granulations 
of  an  ulcer.  The  ulcer  and  surrounding  skin,  as  well  as  the  skin  on 
the  part  from  which  the  grafts  are  to  be  taken,  should  be  rendered 
aseptic  by  the  usual  process.  The  granulations,  if  exuberant,  are  to 
be  curetted  to  the  level  of  the  surrounding  skin;  hemorrhage  should  be 
checked  by  sponge  pressure  and  hot  irrigation  with  normal  salt  solution. 

Reverdin's  method  consists  in  cutting  small  pieces  of  epidermis 
from  a  healthy  part  by  scissors  and  placing  them  on  the  ulcer,  the 
cut  surfaces  being  in  contact  with  the  granulations.  In  Thiersch's 
method  long  strips  of  epidermis  are  cut  with  a  razor  from  the  inner 
side  of  the  thigh  or  arm,  and  carefully  laid  upon  the  ulcer  in  such  a 
manner  as  completely  to  cover  it.  Considerable  skill  is  required  to 
cut  these  strips,  which  should  be  exceedingly  thin,  and  are  best  cut 
while  the  skin  is  on  the  stretch  by  being  drawn  upward  and  downward 
with  the  edge  of  a  narrow  board,  or  by  McBurney's  hooks  (Fig.  122). 


240  INJURIES  AND  DISEASES  OF  THE  SKIN 

When  the  grafts  are  in  place  they  are  covered  with  several  overlapping 
strips  of  rubber  protective  tissue  and  surrounded  by  several  thicknesses 
of  sterile  gauze  wet  with  normal  salt  solution,  and  the  whole  held 
in  place  by  a  bulky  dressing  of  cotton  and  a  snug  bandage.  The 
rubber  tissue  should,  if  possible,  be  left  in  place  for  a  week  or  ten  days. 
After  a  successful  grafting  the  granulations  will  be  covered  with  a 
delicate  bluish  transparent  epidermis,  which  soon  spreads  over  the 
entire  ulcer  and  gradually  thickens.  In  the  subsequent  dressings  the 
rubber  protective  tissue  should  be  used  until  the  grafts  appear 
vigorous,  after  which  any  simple  sterile  dressing  will  answer. 

Halsted  has  suggested  the  use  of  silver  foil  in  place  of  rubber  tissue 
in  the  primary  dressing. 

Wolfe  Grafts. — The  use  of  grafts  made  by  transplanting  sections  of 
the  entire  skin  may  be  necessary  in  case  of  marked  cicatricial  deformity, 
on  account  of  the  fact  that  in  these  cases  the  Thiersch  grafts  show  a 


Fig.  122. — McBurney's  hook. 

tendency  to  contraction  and  produce  a  recurrence  of  the  deformity. 
This  method  was  suggested  by  Wolfe,  of  Glasgow,  who  first  employed 
it  for  the  relief  of  ectropion.  It  has  been  extensively  employed  in 
other  localities,  as  about  joints  and  over  exposed  tendons. 

The  cicatricial  tissue  should  first  be  completely  removed  and  the 
hemorrhage  checked  by  hot  compresses  and  pressure.  An  area  of 
healthy  skin  somewhat  larger  than  the  denuded  area  is  next  dissected 
from  the  thigh  or  arm  and  transferred  to  the  original  wound.  This 
is  held  in  position  by  a  few  sutures,  and  the  wound  dressed  as  after  the 
Thiersch  graft.  It  is  desirable  to  allow  the  primary  dressing  to  remain 
in  place  for  from  six  to  ten  days,  and  when  dressed  to  disturb  the 
graft  as  little  as  possible,  as  the  early  vascular  connections  are  extremely 
delicate  and  easily  ruptured. 

This  method  has  not  been  as  successful  as  the  others,  and  for  that 
reason  is  rarely  used.  Dowd  has,  however,  reported  a  series  of  cases 
where  he  obtained  success  in  over  90  per  cent,  of  his  operations. 


CHAPTER   XL 

THE  SURGERY  OE  THE  PERICARDIUM  AND  HEART.1 

INJURIES  OF  THE  PERICARDIUM. 

Wounds  of  the  Pericardium. — Wounds  of  the  pericardium  are 
usually  complicated, 'although  independent  injury  of  the  pericardium 
may  occur.  Clinically  a  wound  of  the  pericardium  cannot  be  differ- 
entiated from  one  involving  the  heart.  The  outcome  of  these  cases 
depends  largely  upon  the  associated  injuries  and  subsequent  complica- 
tions. The  operative  treatment  is  discussed  under  Wounds  of  the 
Heart. 

Foreign  Bodies  in  the  Pericardium. — The  presence  of  a  foreign  body 
in  the  pericardium  is  a  very  common  complication  of  pericardial 
wounds,  and  even  more  frequent  in  association  with  wounds  of  the 
heart.  Bullets,  needles,  pins  and  fragments  of  weapons  are  the  foreign 
bodies  usually  found. 

A  small  body,  such  as  a  bullet,  sometimes  becomes  encysted  in  the 
pericardial  sac  without  interfering  with  the  general  health  of  the 
patient.  When  infection  is  introduced  with  a  foreign  body,  suppura- 
tive pericarditis  may  develop.  Plastic  pericarditis  is  a  common 
sequel  to  pericardial  wounds,  but  complete  adhesions  rarely  follow. 
The  principles  of  treatment  are  discussed  under  Foreign  Bodies  in 
the  Heart. 

DISEASES  OF  THE  PERICARDIUM. 

Inflammatory  Exudates. — -The  large  majority  of  operations  upon 
the  pericardium  are  undertaken  to  rid  it  of  fluid  contents  of  inflam- 
matory origin. 

Serous  Effusions. — It  must  be  emphasized  that  a  serous  effusion 
is  usually  absorbed,  that  its  presence  rarely  affects  the  action  of  the 
heart  except  when  it  is  extremely  large  in  amount,  that  the  impaired 
heart  action  is  due  chiefly  to  associated  myocarditis,  that  toxic  symp- 
toms due  to  serous  effusions  are  not  marked,  and  that  any  prolonged 
pericarditis  may  be  associated  with  the  formation  of  extensive  intra- 
pericardial  adhesions  which  frequently  produce  permanent  impairment 
of  the  heart  action. 

1  This  revision  is  largely  an  abstract  of  an  article  by  Dr.  Pool  in  Johnson's  Operative 
Therapeusis. 
16 


242  SURGERY  OF  PERICARDIUM  AND  HEART 

Indications  for  Treatment. — A  serous  effusion  should  be  removed 
as  soon  as  there  is  evidence  that  its  presence  embarrasses  the  heart. 
In  general  the  following  rules  should  be  followed:  Small  serous 
effusions  should  receive  symptomatic  treatment;  large  serous  effusions 
which  persist  after  a  brief  trial  of  non-operative  measures  should  be 
removed.  If  the  fluid  reaccumulates  rapidly  or  in  large  amount, 
it  again  should  be  removed.  For  tjie  removal  of  serous,  serofibrinous, 
and  hemorrhagic  exudates,  paracentesis  is  the  operation  most  fre- 
quently employed,  and  is  the  one  usually  to  be  recommended.  The 
immediate  result  of  the  removal  of  serous  effusions  is  usually  disap- 
pointing because  the  embarrassment  of  the  heart  action,  as  a  rule, 
is  not  due  to  the  presence  of  the  fluid  but  to  an  associated  myocarditis. 

Suppurative  Pericarditis. — This  condition  represents  an  abscess 
corresponding  to  a  part  or  the  whole  of  the  pericardial  sac.  The 
most  frequent  organisms  are  the  streptococcus,  staphylococcus,  and 
pneumococcus.  The  exudate  is  usually  purulent  from  the  beginning 
of  the  attack,  although  occasionally  it  develops  in  the  course  of  a  non- 
suppurative pericarditis.  As  a  rule,  purulent  pericarditis  is  secondary 
in  the  course  of  pyogenic  infection,  and  under  such  conditions  it 
frequently  constitutes  a  "terminal  infection;"  in  rare  cases  sup- 
purative pericarditis  is  primary;  in  some  cases  the  infection  is  intro- 
duced through  a  wound. 

Suppurative  pericarditis  is  characterized  by  the  local  signs  of  peri- 
carditis,with  effusion  and  constitutional  symptoms  of  a  septic  character. 
The  fact  that  the  pericarditis  is  frequently  a  secondary  lesion  causes 
its  presence  to  be  overlooked  in  many  cases.  In  children  the  symp- 
toms of  pericarditis  are  particularly  apt  to  be  masked.  On  the  other 
hand,  in  many  cases  where  the  lesion  has  been  recognized  and  the 
pericardium  drained,  the  operation  has  been  unsuccessful  because  a 
coexisting  purulent  focus,  especially  empyema,  has  been  overlooked. 
It  follows  that  in  septic  processes  it  is  necessary  to  watch  for  the 
development  of  pericarditis;  moreover,  the  recognition  of  such  a 
condition  should  not  cause  less  thoroughness  in  the  search  for  other 
foci. 

Suppurative  pericarditis  demands  immediate  incision  and  drainage. 

Tuberculous  Pericarditis. — Tuberculous  pericarditis  is  usually  asso- 
ciated with  other  tuberculous  lesions,  especially  of  the  lungs,  pleurae 
or  lymph  nodes.  The  tuberculous  nature  of  the  process  is  suggested 
by  evidence  of  tuberculosis  elsewhere,  by  bloody  fluid  on  paracentesis, 
and  by  appropriate  tests  of  the  fluid  aspirated. 

Treatment.— The  choice  of  operative  procedure  lies  between  aspira- 
tion, pericardiotomy  and  drainage,  and  pericardiotomy  followed  by 
suture  without  drainage.  Suppurative  exudates  should  in  general 
be  drained;  serous  exudates  aspirated,  or,  if  this  is  unsuccessful  by 
reason  of  incomplete  evacuation  or  rapid  recurrence,  pericardiotomy 
with  closure  should  be  performed,  as  in  tuberculous  peritonitis. 


OPERATIONS  ON  THE  PERICARDIUM  243 

OPERATIONS  ON  THE  PERICARDIUM. 

Puncture  or  Aspiration  of  the  Pericardium  (Parencentesis  Peri- 
cardii).— Its  uses  may  be  summarized  as  follows: 

1.  As  a  diagnostic  measure  to  determine  the  presence  and  character 
of  an  exudate. 

2.  As  a  therapeutic  measure:  (a)  in  serous  or  serofibrinous  pericardi- 
tis, for  the  relief  of  the  heart  when  embarrassed  by  the  pressure  of 
the  fluid,  in  cases  where  the  rapid  increase  of  such  an  exudate  acutely 
threatens  the  heart  and  lungs;  (6)  for  the  removal  of  large  serous 
accumulations  which  resist  other  therapeutic  measures. 

3.  As  an  emergency  procedure,  in  compression  of  the  heart  by 
hemorrhage  (heart  tamponade)  when  incision  of  the  pericardium  must 
be  postponed. 

Paracentesis,  as  compared  with  pericardiotomy,  presents  two 
striking  disadvantages:  (1)  it  exposes  to  the  danger  of  accidental 
injury  of  the  heart,  the  coronary  artery  or  vein,  the  pleura  and  internal 
mammary  artery;  (2)  the  evacuation  of  the  exudate  is  imperfect. 

The  following  sites  are  especially  well  adapted  for  the  evacuation 
of  the  pericardium: 

1.  A  point  slightly  internal  to  the  left  limit  of  dulness,  in  the  fifth 
or  sixth  intercostal  space. 

2.  A  point  in  the  angle  formed  by  the  insertion  of  the  seventh 
left  cartilage  with  the  base  of  the  xiphoid  process.  The  choice 
between  the  two  sites  must  depend  upon  the  individual  indications. 
The  inner  site  exposes  to  greater  danger  of  injury  to  the  heart;  the 
outer  involves  the  danger  of  infection  of  the  pleural  cavity. 

In  general  in  small  effusions  the  chondroxiphoid  angle  is  elected; 
in  large  effusions,  the  outer  site. 

Pericardiotomy,  or  incision  of  the  pericardium,  is  indicated  for  the 
evacuation  of  an  infectious  exudate;  for  the  removal  of  a  foreign 
body;  for  exploration  in  doubtful  cases  of  heart  injury. 

Pericardiotomy  for  the  Evacuation  of  a  Purulent  Exudate. — In  the 
treatment  of  suppurative  pericarditis,  the  method  of  pericardiotomy 
to  be  efficient  must  provide  for  satisfactory  drainage.  Therefore  the 
pericardium  should  be  opened  at  its  lowest  point  and  the  opening 
should  ensure  ready  egress  for  accumulations  in  both  the  right  and 
left  spaces  of  the  pericardial  sac.  Further,  the  method  must  be 
sufficiently  simple  to  be  rapidly  performed;  if  necessary,  under  local 
anesthesia.  Local  anesthesia  is  frequently  imperative  because  the 
heart  is  apt  to  be  dilated  and  insufficient. 

The  two  methods  most  appropriate  for  drainage  in  suppurative 
pericarditis  are : 

1.  Resection  of  sixth  costal  cartilage  (Kocher). 

2.  Resection  of  seventh  or  sixth  and  seventh  costal  cartilages 
(Rehn). 

The  results  of  pericardiotomy  for  purulent  pericarditis  are  neces- 


244  SURGERY  OF  PERICARDIUM  AND  HEART 

sarily  modified  by  the  gravity  of  the  fundamental  disease,  but  striking 
cures  have  followed  operation  in  apparently  hopeless  cases.  The 
mortality  of  pericardiotomy  for  suppurative  pericarditis  is  about 
60  per  cent. 

Cardiolysis ;  Pericardiolysis ;  Pericardial  Thoracolysis. — As  a  result 
of  pericarditis,  the  pericardial  sac  may  become  obliterated  to  a  variable 
degree  by  the  welding  together  of  its  two  layers  through  more  or  less 
solid  adhesions;  moreover,  as  a  result  of  mediastinitis  or  pleurisy  firm 
adhesions  may  be  formed  between  the  pericardium  and  neighboring 
structures.  In  consequence  of  such  adhesions  the  heart  action  is 
restricted,  and  the  heart  is  required  to  do  much  extra  work  in  over- 
coming the  resistance.  The  condition  is  characterized  clinically  by  a 
more  or  less  marked  systolic  retraction  of  the  chest  wall  over  the  heart 
with  a  proportionate  diastolic  resiliency. 

Brauer's  operation  of  "cardiolysis"  consists  in  the  removal  of 
the  ribs  which  interfere  with  the  cardiac  systole.  The  rigid  bony 
wall  is  thus  replaced  by  a  soft  elastic  covering  which  is  easily  moved 
by  the  heart.  A  flap  is  formed  on  the  left  side  corresponding  to  the 
fourth,  fifth  and  sixth  cartilages  and  ribs,  the  base  of  the  flap  lying  in 
the  axillary  line  and  the  free  edge  at  the  sternal  margin.  The  soft  parts 
including  skin  and  muscles  are  turned  back,  and  the  exposed  portions 
of  the  fourth,  fifth  and  sixth  ribs  and  their  costal  cartilages  are 
removed.  The  ultimate  results  are  said  to  be  excellent,  but  depend 
upon  the  degree  of  myocarditis  and  secondary  changes  in  other 
organs. 

INJURIES  OF  THE  HEART. 

Foreign  Bodies  in  the  Heart. — Foreign  bodies  may  reach  the  heart: 
through  the  walls  of  the  thorax,  the  most  common  route;  through 
the  bloodvessels;  through  the  respiratory  passages;  or  the  digestive 
tract,  very  rarely.  There  are  cases  in  which  the  point  of  entrance 
of  the  foreign  body,  or  the  mechanism  of  its  passage  to  the  heart, 
cannot  be  ascertained. 

Diagnosis. — The  diagnosis  of  a  foreign  body  in  the  heart  and  its 
accurate  localization  rests  essentially  upon  the  radiographic  findings, 
as  the  clinical  picture  is  in  no  way  pathognomonic. 

Treatment. — In  the  surgical  treatment  of  foreign  bodies  in  the  heart, 
the  operator  must  be  guided  by  individual  requirements.  (1)  Imme- 
diate treatment:  In  the  case  of  small  bodies  such  as  bullets,  wads, 
etc.,  which  have  been  introduced  through  gunshot  wounds,  the  im- 
mediate treatment  is  that  of  a  wound  or  a  suspected  wound  of  the 
heart.  The  recognition  and  removal  of  the  foreign  body  is  a  coinci- 
dence and  not  the  object  of  the  operation.  (2)  Late  treatment: 
Foreign  bodies  which  have  become  lodged  in  the  heart  demand  opera- 
tion only  if  they  interfere  with  the  cardiac  function.  In  that  case, 
the  heart  should  be  exposed;  a  body  embedded  in  the  wall  and  readily 


INJURIES  OF  THE  HEART  245 

accessible  should  he  extracted,  one  in  an  inaccessible  position,  as  the 
interior  of  the  heart,  must,  as  a  rule,  be  left. 

Wounds  of  the  Heart.1 — Injuries  to  the  heart  are  most  frequently 
caused  by  stab  or  gunshot  wounds.  The  heart  wall  may  be  injured 
in  part  or  the  whole  of  its  thickness.  Associated  lesions  are  frequently 
present,  especially  wounds  of  the  pleurae,  lungs,  coronary  artery  or 
internal  mammary  artery. 

Hemorrhage  from  a  heart  wound  is  almost  always  free.  The  blood 
may  accumulate  in  and  distend  the  pericardial  sac  (hemopericardium), 
or  it  may  enter  the  pleural  cavity  if  the  pericardial  wound  is  such 
as  to  afford  free  communication  between  the  two  cavities.  When  the 
blood  accumulates  within  the  pericardial  sac  the  heart  action  becomes 
impeded  by  intrapericardial  tension  to  an  extent  dependent  upon 
the  amount  and  rapidity  of  the  hemorrhage.  The  flow  of  blood  is 
retarded  and  finally  stopped;  ventricular  contraction  is  impeded  and 
ultimately  arrested.  This  is  known  as  heart  tamponade  (Rose), 
which  may  be  defined  as  gradual  impairment  and  ultimate  cessa- 
tion of  the  heart  action  as  a  result  of  intrapericardial  tension  due  to 
hemorrhage  into  the  pericardial  sac. 

Symptoms. — The  symptoms  of  a  wound  of  the  heart  are  dependent 
upon  shock,  hemorrhage  and  associated  lesions.  Shock  is  usually 
marked.  Hemorrhage  may  cause:  (1)  hemothorax,  with  symptoms 
of  internal  hemorrhage  and  signs  of  fluid  in  the  pleural  cavity  or,  (2) 
hemopericardium,  wTith  the  objective  signs  of  dilatation  of  the  peri- 
cardial sac  and  more  or  less  marked  symptoms  of  heart  tamponade, 
which  is  evidenced  by  cyanosis,  dyspnea,  small,  weak,  irregular  pulse, 
enlargement  of  the  cardiac  dulness  with  feeble,  distant  heart  sounds. 

Diagnosis. — The  diagnosis  is  often  doubtful.  There  is  no  typical 
clinical  picture  whereby  a  wounded  heart  can  always  be  diagnosed, 
especially  in  the  first  few  hours  after  injury.  The  classical  syndrome, 
"heart  tamponade,"  due  to  intrapericardial  pressure,  is  more  often 
absent  than  present  (Borchardt) ;  physical  signs  in  the  cardiac  region, 
such  as  abnormal  sounds  and  increased  dulness,  are  frequently  incon- 
clusive; the  position  and  direction  of  the  surface  wound  are  not  always 
convincing;  wrhile  the  suggestive  symptoms  of  internal  hemorrhage, 
hemothorax,  hemopneumothorax  may  originate  entirely  in  thoracic 
lesions  other  than  a  heart  injury. 

Treatment. — Immediate  exploration  is  indicated  even  when  the 
diagnosis  is  in  doubt  and  a  heart  wound  is  probable  but  not  positive. 
Operation  is  the  proper  procedure  for  the  following  reasons:  The 
diagnosis  of  heart  wounds  is  frequently  uncertain,  especially  soon  after 
the  injury;  the  prognosis  becomes  progressively  poorer  with  delay; 
the  immediate  and  late  results  of  operative  treatment  have  been 
much  better  than  non-operative. 

E.  Hesse  (1911)   collected  219  cases  of  cardiorrhaphy  with   116 

1  The  section  on  Wounds  of  the  Heart  is  abstracted  from  an  article  by  Dr.  Pool  in 
Annals  of  Surgery,  1912,  lv,  485. 


246  SURGERY  OF  PERICARDIUM  AND  HEART 

deaths  and  103  recoveries.  He  points  out  that  this  ratio  gives  a 
false  impression  of  the  percentage  of  cures,  because  numerous  failures 
doubtless  are  not  reported. 

Technic  of  Operation. — Careful  preparation  of  the  field  of  operation 
is  essential,  since  many  fatal  results  have  been  due  to  sepsis. 

Light  general  anesthesia,  preferably  ether,  should  be  given  when 
there  are  signs  of  sensibility. 

It  is  important  to  recognize  that  in  a  large  proportion  of  heart 
wounds  the  pleura  is  opened  and  that  an  extrapleural  cardiorrhaphy 
is  rarely  possible. 

Differential  pressure  offers  marked  advantages,  chiefly  by  elimi- 
nating the  immediate  and  minimizing  the  later  dangers  due  to  pneumo- 
thorax. Its  use  expedites  the  operation  by  allowing  a  free  transpleural 
exposure.  But  prior  to  the  control  of  bleeding  from  the  heart  wound 
positive  pressure  should  be  used  with  great  care  because  it  may  increase 
hemorrhage. 

A  transpleural  exposure  with  long  intercostal  incision  (Wilms)  is 
ordinarily  the  best  because  it  affords  free  exposure  of  the  heart,  can  be 
applied  much  more  quickly  than  other  procedures,  and  causes  less  hemor- 
rhage. This  exposure  should  be  employed  when  differential  pressure  is 
used,  when  speed  is  important,  or  when  pneumothorax  is  present. 

An  effort  to  do  an  extrapleural  operation  is  warranted  under  certain 
conditions.  The  indications  are:  Differential  pressure  not  available, 
pneumothorax  not  present,  no  injury  to  the  pleura  such  as  would 
render  the  effort  useless.  Under  these  conditions,  an  osteoplastic  flap 
with  pedicle  outward  should  be  employed. 

In  some  cases  in  which  the  diagnosis  is  in  doubt,  extrapleural 
exploratory  pericardiotomy  may  be  performed  by  resection  of  the 
sixth  costal  cartilage  as  in  the  primary  incision  of  Kocher's  flap 
operation.  «% 

Atypical  procedures  are  at  times  indicated. 

Fine  vaselined  silk  on  a  curved  intestinal  needle  is  the  best  material 
for  heart  suture. 

The  pericardium  should  be  closed  with  interrupted  catgut  sutures. 

Pericardial  drainage  may  be  dispensed  with  in  some  cases  when 
there  is  short  exposure  and  little  trauma.  A  drain  should  enter  the 
pericardium  to  a  slight  extent  when  the  nature  of  the  wound  renders 
infection  probable.  But  in  doubtful  cases  it  is  best  to  insert  a  drain 
down  to  but  not  into  the  pericardial  wound,  a  small  part  of  which 
should  be  left  unsutured.  In  this  way  an  exit  is  provided  for  the 
large  accumulation  of  serum  which  is  likely  to  occur  after  the  opera- 
tion, and  no  irritation  of  the  pericardium  is  caused  by  the  presence 
of  a  drain. 

Pleural  drainage  is  a  prophylactic  step  which  is  often  unnecessary 
and  likely  to  be  harmful.  Unless  there  is  a  strong  probability  of 
infection,  it  is  better  to  delay  drainage  until  infection  has  occurred 
and  then  to  do  secondary  thoracotomy. 


INJURIES  OF  THE  HEART  247 

Cardiac  Massage. — Direct  massage  has  been  recommended  for  arrest 
of  the  heart  during  operation.  The  aim  is  to  stimulate  the  heart  to 
renewed  activity.  It  must  be  begun  within  five  minutes  after  cessation 
of  the  heart  beats  (Jurasz),  and  the  usual  measures  for  the  resuscita- 
tion of  a  patient  should  be  employed  at  the  same  time  as  the  massage. 
Injurious  sequelae  have  not  been  noted  after  recovery,  but  frequent 
failures  must  be  expected. 

The  methods  of  approaching  the  heart  are  as  follows: 

1.  Transthoracic  route.  This  consists  in  lifting  a  costochondral 
flap,  opening  the  pericardium  and  inserting  the  hand. 

2.  Transdiaphragmatic  method.  A  vertical  incision  is  made  below 
the  ensiform  cartilage,  and  a  second  incision  through  the  diaphragm 
into  the  pericardium. 

3.  Subdiaphragmatic  method  differs  from  the  transdiaphragmatic 
in  that  only  the  abdominal  incision  is  made;  the  heart  is  massaged 
with  the  hand  beneath  the  flaccid  diaphragm. 

In  the  transthoracic  method  the  pleura  is  generally  opened,  entailing 
pneumothorax.  The  transdiaphragmatic  method  avoids  pneumo- 
thorax, but  the  method  has  not  shown  advantages  over  the  sub- 
diaphragmatic method.  The  subdiaphragmatic  method,  according 
to  most  authorities,  is  the  simplest  and  quickest  for  making  the  heart 
accessible  for  massage,  and  affords  the  best  results.  Jurasz  is  in  favor 
of  employing  this  method  in  all  cases  in  which  the  abdominal  cavity 
has  been  already  opened.  In  other  cases,  it  is  questionable  whether 
time  should  be  consumed  in  opening  the  abdomen. 

Experimental  Surgery  of  the  Heart.1 — The  bad  results  following 
intrathoracic  operations  in  experimental  as  well  as  clinical  surgery  are 
due  to  a  lack  of  adaptation  of  the  technique  to  the  physiological 
conditions  of  the  chest.  The  complications  which  often  kill  the  animal 
or  the  patient  are  brought  about  directly  or  indirectly  by  the  infection 
of  the  pleural  or  pericardiac  cavities,  or  by  the  respiratory  disorders 
caused  by  the  penetration  of  the  air  into  the  thorax. 

"The  success  of  the  more  complex  intrathoracic  operations  depends 
upon  the  observance  of  a  number  of  minute  details  of  technic.  It 
is  necessary  mainly  to  remove  some  of  the  factors  causing  irritation 
of  the  pleura. 

"In  the  more  extensive  operations,  the  Meltzer  and  Auer  method 
of  intracheal  insufflation  should  be  used. 

"Theoretically,  many  operations  can  be  performed  on  the  heart; 
incision  and  dilatation  of  stenosed  valves,  cuneiform  resection  and 
stenosis  of  the  upper  part  of  the  ventricle  in  cases  of  mitral  insufficiency, 
curettage  of  endocardiac  vegetations,  grafting  of  new  vessels  on  the 
auricle  and  ventricle,  collateral  circulation  between  two  cavities  of 
the  heart,  aortocoronary  anastomosis,  etc."  Carrel  states  that  the 
"plastic  operations  on  the  heart  are  not  very  much  more  difficult 

1  Carrel,  Annals  of  Surgery,  1910,  lii,  83. 


248  SURGERY  OF  PERICARDIUM  AND  HEART 

than  on  other  parts  of  the  body.  But  to  perform  the  operations 
without  disturbing  in  an  irreparable  manner  the  functions  of  the 
nervous  system  and  of  the  heart  itself  is  a  very  complicated  prob- 
lem. The  technie  of  these  operations  is  far  from  being  completely 
developed." 

WOUNDS  OF  THE  BLOODVESSELS. 

(See  Hemorrhage,  Chapter  VI). 

DISEASES  OF  THE  BLOODVESSELS. 

Acute  Arteritis. — Inflammation  of  one  or  more  coats  of  the  arteries 
may  be  due  to  a  variety  of  causes.  Acute  infective  arteritis  may  arise 
from  extension  of  an  infective  process  from  the  surrounding  tissues  to 
the  artery  itself,  resulting  in  a  round-cell  infiltration  of  the  vessel  walls, 
with  softening  and  necrosis,  a  condition  often  giving  rise  to  secondary 
hemorrhage  in  suppurating  wounds;  or  the  process  may  arise  from  the 
interior  of  the  vessel  from  the  deposit  of  infected  thrombi,  as  seen  in 
pyemic  processes,  and  as  the  result  of  ulcerative  endocarditis. 

Chronic  Endarteritis. — Chronic  endarteritis  is  a  slowly  developing 
inflammatory  process  beginning  in  the  interior  of  an  artery  and  extend- 
ing to  the  media  and  adventitia.  It  occurs  in  two  forms,  the  athero- 
matous and  the  obliterative. 

Atheromatous. — In  the  atheromatous  variety  there  is  at  first  a 
circumscribed  round-cell  infiltration  of  the  intima  and  media,  which 
later  undergoes  fatty  degeneration,  forming  a  pultaceous  mass  which 
may  separate,  leaving  a  loss  of  substance  on  the  interior  of  the  vessel, 
called  an  atheromatous  ulcer.  This  causes  a  weakening  of  the  vessel- 
wall  at  that  point,  which  may  later  dilate  and  form  an  aneurism,  or 
the  ulcer  may  be  covered  by  a  calcareous  plate.  A  plate  of  this  kind 
may  subsequently  become  loosened  and  be  carried  away  by  the  blood- 
current,  forming  an  embolus,  or  the  blood  may  find  its  way  underneath 
it  and  eventually  separate  the  coats  of  the  artery  and  form  a  dissecting 
aneurism.  A  compensatory  thickening  of  the  adventitia  often  occurs 
in  these  cases,  preventing  the  formation  of  an  aneurism.  Athero- 
matous endarteritis  occurs  chiefly  in  the  aged,  and  in  those  who  have 
suffered  from  syphilis,  nephritis,  or  the  abuse  of  alcohol.  It  affects 
chiefly  the  larger  arteries. 

Obliterative. — In  the  obliterative  form  the  infiltration  of  the  intima 
is  more  uniform,  and  causes  a  gradual  diminution  in  the  lumen  of  the 
vessel  with  final  obliteration.  This  occurs  more  commonly  in  the 
smaller  vessels,  and  is  generally  due  to  syphilis. 

Fatty  Degeneration. — Fatty  degeneration  of  the  intima  may  occur 
independently  of  atheroma  and  occasion  a  weakening  of  the  vessel. 

Calcification  of  the  Media. — Calcification  of  the  media  occurs  in  old 
people,  and  renders  the  arteries  rigid  and  narrow.  It  is  most  frequently 
observed  in  the  vessels  of  the  extremities,  chiefly  at  the  points  of 


DISEASES  OF  THE  BLOODVESSELS  249 

departure  of  the  principal  branches.  Tt  causes  impaired  nutrition  of 
the  parts,  often  terminating  in  senile  gangrene. 

Aneurism.  An  aneurism  is  a  pulsating  hollow  tumor  filled  with 
blood,  communicating  with  the  interior  of  an  artery.  Two  varieties  are 
commonly  described:  the  true  or  spontaneous  aneurism,  and  the  false 
or  traumatic  aneurism.  A  true  aneurism  is  one  in  which  the  walls 
are  formed  by  one  or  more  of  the  coats  of  the  artery,  and  is  in  reality 
dilatation  of  the  vessel;  a  false  aneurism  is  one  in  which  the  walls  are 
formed  by  the  surrounding  perivascular  tissues  thickened  by  blood 
clot  and  inflammatory  exudate,  and  is  due  to  rupture  of  the  vessel. 

Causation. — Two  factors  may  be  present  in  the  production  of  a  true 
aneurism;  an  increase  in  the  blood-pressure  and  a  weakening  of  the 
arterial  wrall.  The.  causes  which  increase  blood-pressure  are  mental 
or  physical  strain,  the  abuse  of  alcohol,  hypertrophy  of  the  heart,  and 
renal  disease;  those  which  weaken  the  arterial  wall  are  trauma,  acute 
arteritis,  atheroma,  gummatous  infiltration,  or  obliterating  endarteritis 
of  the  vasa  vasorum.  Thus,  true  aneurisms  occur  most  frequently 
between  forty  and  sixty,  the  period  of  life  when  physical  and  mental 
strain  are  apt  to  be  greatest,  while  the  heart  action  is  still  vigorous, 
and  when  degenerative  changes  begin  to  occur.  For  obvious  reasons 
they  are  more  frequent  in  men  than  in  women.  Syphilis  undoubt- 
edly is  the  most  important  etiologic  factor,  the  Wassermann  reaction 
being  positive  in  about  90  per  cent,  of  the  cases. 

Development  and  Varieties  of  Aneurism. — As  a  result  of  increased 
blood-pressure  a  portion  of  one  of  the  larger  arteries  which  has  become 
weakened  by  atheromatous  changes  or  from  any  other  cause  shows  a 
tendency  to  dilate.  The  dilatation  slowly  progresses  at  first,  and  may 
involve  the  entire  vessel,  giving  rise  to  a  spindle-shaped  swelling  or 
fusiform  aneurism  (Fig.  123).  If  only  one  portion  of  the  arterial  wall 
gives  way,  a  pouch-like  protrusion  occurs,  forming  a  sacculated  aneu- 
rism (Fig.  124).  If  an  atheromatous  ulcer  forms  or  if  the  intima  is 
eroded  by  the  separation  of  a  calcareous  plate,  the  blood  dissects  its 
way  between  the  arterial  coats  and  forms  a  dissecting  aneurism  (Fig. 
125),  the  cavity  of  which  many  communicate  with  the  lumen  of  the 
artery  at  one  or  two  points.  Aneurisms  occasionally  result  from  the 
plugging  of  small  terminal  arteries  by  emboli.  The  dilatation  and 
elongation  of  an  artery  or  of  several  arterial  branches  forming  a  pulsat- 
ing mass  is  spoken  of  as  a  cirsoid  aneurism  (Fig.  126).  Minute  miliary 
aneurisms  occasionally  form  on  the  arterioles,  especially  in  the  pia 
mater,  and  by  their  rupture  give  rise  to  apoplexy. 

False  or  traumatic  aneurism  is  generally  the  result  of  a  wound 
of  an  artery  or  of  rupture  of  a  true  aneurism.  If  as  a  result  of  an 
injury,  as  a  stab  or  gunshot  wound,  an  arterial  trunk  is  injured,  blood 
is  poured  out,  and  a  hematoma  forms  around  the  vessel.  If  the  resist- 
ance of  the  surrounding  tissues  is  such  as  to  prevent  a  wide  diffusion 
of  the  extravasated  blood,  the  peripheral  portion  coagulates,  forming  a 
kind  of  sac  which  is  later  strengthened  by  an  inflammatory  exudate. 


250 


SURGERY  OF  PERICARDIUM  AND  HEART 


If  the  wound  in  the  vessel  is  not  occluded  by  a  clot,  fluid  blood  from 
the  artery  is  continually  pumped  into  the  hollow  centre  of  the  mass, 


Fig.  123.— Fusiform 
aneurism. 


Fig.  124.— Sacculated 
aneurism. 


Fig.  125. — Dissecting 
aneurism. 


forming  a  gradually  increasing  pulsating  tumor.  If  the  injury  wounds 
not  only  an  artery  but  also  a  neighboring  vein,  the  blood  may  pass 
from  the  artery  directly  into  the  vein,  forming  an  arteriovenous  aneu- 
rism.    Two  varieties  of  arteriovenous  aneurism  exist:  one,  in  which 


Fig.  126. — Cirsoid  aneurism.    (Burns.) 


the  union  between  the  injured  vessels  is  close,  called  an  aneurismal 
varix  (Fig.  127) ;  the  other,  in  which  the  blood  passes  from  the  artery 


X 

h 
< 

a. 


< 


DISEASES  OF  THE  BLOODVESSELS 


251 


into  a  false  aneurism  and  then  into  the  vein,  which  is  separated  from 
the  artery  by  the  aneurismal  sac,  called  a  varicose  aneurism  (Fig.  128). 
In  all  aneurisms  there  is  a  tendency  to  gradual  increase  in  size. 
In  true  aneurisms  the  intima  and  media  frequently  become  atrophied, 
while  the  adventitia  thickens  and  occasionally  makes  up  the  entire 
wall  of  the  tumor.  As  the  aneurism  enlarges  a  deposit  of  fibrin  takes 
place  on  the  interior  of  the  sac,  giving  rise  to  great  thickening  of  the 
walls.  This  deposit  is  laminated,  and  in  rare  cases  develops  to  such 
an  extent  as  finally  to  occlude  the  vessel  and  result  in  spontaneous 
cure.  Spontaneous  cure  is  also  rarely  effected  by  a  blood-clot  or  the 
separation  of  a  mass  of  fibrin  from  the  walls  of  the  sac,  which  plugs 
the  outlet  or  the  vessel  beyond  the  tumor.  Spontaneous  cure  may  also 
take  place  in  false  aneurisms  and  in  the  arteriovenous  varieties. 


Fig.  127. — Aneurismal  varix. 


Fig.  128. — Varicose  aneurism. 


The  growth  of  an  aneurism  will  cause  great  destruction  of  neigh- 
boring tissues.  The  more  resisting  tissues,  as  bone  and  cartilage, 
suffer  more,  as  a  rule,  than  the  softer  and  more  yielding  structures. 
Thoracic  aneurism  not  infrequently  causes  erosion  of  the  spinal 
column  and  pressure  on  the  cord,  as  well  as  bulging  and  atrophy 
of  the  sternum  and  ribs.  Rupture  of  an  aneurism  may  occur,  and 
suppuration  has  been  observed,  generally  the  result  of  infection  of  a 
wound  from  distal  or  proximal  ligature. 

Diagnosis. — The  early  symptoms  complained  of  by  patients  suffering 
from  aneurism  are  usually  only  a  swelling  and  a  disagreeable  sense  of 
throbbing  over  the  region  of  an  arterial  trunk.  Later,  as  the  tumor 
enlarges,  there  may  be  more  or  less  pain,  and  if  the  aneurism  presses 
upon  and  erodes  bone,  the  pain  may  be  very  severe.     On  examination 


252  SURGERY  OF  PERICARDIUM  AND  HEART 

a  tumor  is  found  which  pulsates  synchronously  with  the  heart.  The 
tumor  is,  as  a  rule,  oval,  elastic,  and  gives  one  the  feeling  that  it 
contains  moving  fluid.  If  the  interior  of  the  tumor  is  largely  filled 
with  fibrin,  pulsation  may  be  faint  and  palpation  may  give  the  impres- 
sion of  a  solid  mass.  As  a  rule,  the  tumor  expands  in  every  direction 
with  each  heart  systole,  and  if  grasped  between  the  fingers  or  hands  in 
any  diameter  expansile  pulsation  will  be  felt.  Aneurisms,  as  a  rule, 
are  compressible.  If  steady  pressure  is  made  with  the  hand  over  the 
tumor,  the  size  will  be  markedly  diminished,  and  when  the  pressure  is 
removed  it  will  take  several  beats  of  the  heart  to  regain  its  previous 
dimensions.  Pressure  over  the  main  arterial  trunk,  between  the  tumor 
and  the  heart,  will  cause  the  pulsations  to  cease  and  the  tumor  to  shrink, 
while  pressure  over  the  efferent  portion  of  the  artery  will  cause  it  to 
increase  in  size.  The  pulse  in  the  arteries  beyond  the  aneurism  will 
be  weaker  and  the  beat  somewhat  retarded  if  comparison  is  made  with 
a  corresponding  artery  on  the  other  side  of  the  body.  If  the  tumor 
is  examined  by  the  ear  or  stethoscope,  a  blowing  sound  often  will  be 
heard  synchronous  with  the  pulse,  which  is  transmitted  in  the  direction 
of  the  vessel.  This  aneurismal  bruit  is  loudest  in  the  fusiform  variety 
and  may  be  absent  in  some  saculated  aneurisms.  As  the  aneurism 
increases  in  size  pressure  symptoms  generally  arise,  such  as  neuralgic 
pains,  sensory  and  motor  paralysis  from  pressure  on  nerves,  venous 
congestion  and  edema  from  pressure  on  veins,  various  visceral  dis- 
turbances from  pressure  on  organs,  as  dyspnea  and  aphonia  from 
pressure  or  erosion  of  the  larynx  or  trachea,  dysphagia  from  the  pressure 
of  a  thoracic  aneurism  on  the  esophagus,  cerebral  symptoms  from  the 
pressure  of  an  intracranial  tumor. 

It  is  often  difficult  to  distinguish  between  false  and  true  aneurisms. 
Fake  aneurisms  are  rarely  fusiform,  and  are  often  somewhat  irregular 
in  outline.  Pulsation  may  be  absent,  or  it  may  be  much  more  distinct 
in  one  portion  of  the  tumor  than  in  another.  The  bruit  is  rarely  as 
well  marked  as  in  true  aneurisms. 

In  arteriovenous  aneurisms  there  is  usually  marked  dilatation  of  the 
veins  in  the  neighborhood  of  the  injury,  and  an  exceedingly  loud, 
harsh  bruit  can  be  heard  over  the  entire  region,  which,  if  situated  near 
the  head,  is  extremely  distressing  to  the  patient.  The  dilated,  tor- 
tuous veins  may  form  a  large  pulsating  mass,  easily  compressible  and 
imparting  a  distinct  thrill  to  the  hand  when  palpated  (Plate  X). 

Cirsoid  aneurism  may  appear  as  a  single  tortuous  pulsating  arterial 
trunk  frequently  seen  on  the  scalp,  producing  no  symptoms;  it  may 
consist  of  several  dilated  arteries,  forming  a  pulsating  mass;  or  the 
vascular  dilatation  may  extend  to  the  capillaries  and  venules.  In 
these  conditions  a  tumor  is  present  which  is  somewhat  irregular  in 
outline,  may  be  bluish  in  color,  is  pulsating,  compressible,  and  presents 
a  loud  bruit  on  auscultation.  Dilated  vessels  often  can  be  seen  running 
into  the  mass.     This  condition  is  often  spoken  of  as  pulsating  angioma. 

Rupture  of  an  aneurism  externally  produces  generally  a  rapidly 


DISEASES  OF  THE  BLOODVESSELS  253 

fatal  hemorrhage;  rupture  into  one  of  the  body  cavities  produces 
localized  pain  and  the  symptoms  of  concealed  hemorrhage;  shock, 
pallor,  cold  perspiration,  rapid  and  feeble  pulse,  air  hunger,  and 
syncope;  rupture  of  an  aneurism  into  the  solid  tissues  of  a  part  produces 
severe  lancinating  pain,  sudden  disappearance  of  the  original  tumor, 
and  the  appearance  of  a  diffuse  swelling  in  the  neighboring  tissues, 
with  coldness  and  edema  of  the  parts  supplied  by  the  artery  and  an 
absence  of  the  pulse  in  the  distal  branches. 

Suppuration  of  an  aneurism  is  indicated  by  the  local  and  general 
signs  of  inflammation. 

Treatment. — In  the  treatment  of  aneurisms  an  effort  should  be  made 
to  favor  nature's  method  of  cure,  which  is  by  the  formation  of  a  firm 
fibrinous  occluding  mass  within  the  sac.  This  may  be  accomplished 
by  lowering  the  blood-pressure  and  by  diminishing  the  amount  of 
blood  which  flows  through  the  sac.  Failing  in  this  the  disease  may  be 
cured  by  entirely  cutting  off  the  circulation  through  the  diseased  artery 
with  or  without  extirpation  of  the  tumor. 

Non-operative  Methods. — Absolute  rest  in  bed  combined  with  an 
exceedingly  low  diet,  consisting  of  2  or  3  ounces  of  meat,  6  ounces 
of  bread,  and  6  ounces  of  milk  or  water  each  day;  and  the  use  of  aconite 
and  potassium  iodide,  will  undoubtedly  produce  a  marked  lowering  of 
the  blood-pressure  and  a  diminution  in  the  force  and  frequency  of  the 
heart  beat.  This  treatment  should  be  continued  for  several  weeks 
or  months,  and  during  this  period  the  patient  should  be  kept  free  from 
any  mental  or  emotional  excitement.  The  wearing  of  a  moulded  lead 
plate  weighing  two  or  three  pounds,  made  accurately  to  fit  the  tumor, 
if  practicable,  will  often  prove  of  great  value  when  combined  with  rest 
and  low  diet.  In  aneurisms  of  the  extremities  moderate  pressure  over 
the  tumor  may  be  maintained  by  the  use  of  a  rubber  bandage.  This 
with  elevation  of  the  limb  occasionally  will  succeed  in  arresting  or 
curing  the  disease. 

Treatment  by  proximal  arterial  pressure  has  long  been  favorably 
considered  by  the  profession,  and  many  cases  have  been  cured  by 
it.  It  is,  however,  applicable  to  only  a  limited  number  of  cases. 
The  plan  is  to  cause  constant  pressure  upon  the  artery  at  some  distance 
above  the  tumor.  The  pressure  should,  if  possible,  be  such  as  to 
include  the  artery  but  not  the  vein,  and  to  produce  noticeable  cessation 
of  pulsation  in  the  tumor.  If  the  circulation  through  the  sac  is  entirely 
cut  off,  the  cavity  will  rapidly  fill  with  an  ordinary  red  clot  of  blood. 
If  a  small  amount  of  blood  is  allowed  to  flow  through  the  aneurism, 
a  firm,  white,  fibrinous  clot  will  form  more  slowly,  but  will  be  much  more 
likely  to  remain  and  produce  permanent  occlusion  of  the  cavity  when 
the  pressure  over  the  artery  is  relaxed. 

The  methods  of  arterial  compression  are  two,  the  digital  and  the 
instrumented.  The  digital  is  in  every  way  superior  to  the  instrumental, 
on  account  of  its  accuracy,  the  ease  with  which  it  is  regulated,  and  the 
fact  that  the  vein  generally  can  be  avoided  and  injury  of  the  tissue 


254  SURGERY  OF  PERICARDIUM  AND  HEART 

prevented.  Relays  of  assistants  are  necessary,  and  when  changing, 
the  pressure  of  the  relieved  assistant  should  not  be  relaxed  until  the 
thumb  of  the  relieving  assistant  is  in  place.  The  mechanical  means 
of  arterial  compression  are  by  the  use  of  the  Petit  tourniquet  (Fig. 
129).  Two  of  these  should  be  kept  in  place,  and  the  pressure  point 
changed  every  few  hours.  The  use  of  mechanical  apparatus  for  this 
purpose  is  extremely  painful,  and  often  requires  general  anesthesia. 
During  the  progress  of  this  treatment  the  pressure  should  from  time 
to  time  be  gradually  relaxed  to  determine  the  condition  of  the  tumor. 
When,  after  relaxing  the  compression,  pulsation  is  found  to  be  absent, 
the  outlook  is  favorable.  The  pressure  should,  however,  be  continued 
to  a  moderate  degree  for  from  twenty-four  to  forty-eight  hours  more. 
Violent  massage  or  manipulation  of  the  tumor,  with  a  view  to 
dislodging  a  portion  of  the  laminated  fibrin  to  cause  a  plugging  of 
the  outlet,  is  to  be  condemned  as  a  dangerous  procedure. 


Fig.  129. — Petit's  tourniquet. 

Forcible  flexion  of  the  knee  or  elbow  for  the  cure  of  small  aneurisms 
situated  in  these  regions  has  been  successful  in  a  number  of  instances. 
The  effect  of  the  flexion  is  to  occlude  the  vessel  and  to  produce  direct 
compression  on  the  aneurism,  causing  rapid  clotting  of  the  contained 
blood.  If  the  limb  is  held  in  a  position  of  extreme  flexion,  the  blood 
current  is  entirely  arrested.  If  the  flexion  is  of  moderate  extent,  the 
blood  current  may  only  be  retarded,  favoring  the  formation  of  a  firm, 
fibrinous  mass  within  the  sac.  It  is  desirable  to  bandage  the  limb 
below  the  tumor,  and  after  flexion  to  maintain  the  position  by  means 
of  straps,  bandages,  or  an  elastic  apparatus.  Every  few  hours  the 
flexion  should  be  temporarily  relaxed  to  determine  the  condition  of  the 
tumor.  This  method  should  never  be  employed  in  large  or  thin-walled 
aneurisms,  for  fear  of  rupture. 

Operative  Methods. — Complete  extirpation  of  the  aneurism  with 
ligature  of  all  the  branches  and  closure  of  the  wound,  with  a  view  to 
obtaining  primary  union,  is  the  method  of  choice  when  it  can  be 
safely  carried  out.     It  is  applicable  to  all  accessible  small  aneurisms, 


DISEASES  OF  THE  BLOODVESSELS 


255 


and  in  many  of  the  larger  ones  which  can  be  freely  exposed.  The 
chief  difficulty  experienced  in  carrying  out  this  plan  is  in  separating 
the  tumor  from  the  neighboring  structures,  to  which  it  is  generally 
attached  by  firm  adhesions.  Extirpation  of  a  portion  of  the  main 
venous  trunk  is  often  necessary  on  this  account,  but  its  removal  is 
rarely  attended  with  serious  symptoms,  as  the  pressure  of  the  tumor 
has,  as  a  rule,  already  caused  the  venous  circulation  to  be  carried 
on  by  other  channels.  If  large  nerve-trunks  or  other  important 
structures  are  in  clanger  of  being  injured,  a  portion  of  the  sac  may 
be  left. 

The  method  is  to  expose  the  tumor  by  a  long  incision  which  extends 
above  and  below  sufficiently  to  give  a  good  exposure  of  the  vessels. 


Fig.  130.— Double  ligature. 


Fig.  131. — Proximal  liga- 
ture.    (Anel.) 


Fig.    132. — Proximal    liga- 
ture.    (Hunter.) 


The  artery  above  and  below  the  tumor  should  be  double  ligated  and 
cut  (Fig.  130).  The  aneurism  is  then  dissected  from  its  bed  and  other 
branches,  if  found,  doubly  ligated,  and  divided.  Considerable  bleeding 
may  occur  from  the  separated  adhesions,  which  should  be  controlled 
by  ligature,  hot  water,  or  hydrogen  peroxide,  after  which  the  wound 
should  be  closed  and  a  dressing  applied.  In  the  extremities  a  splint 
or  stiff  bandage  should  be  used  to  insure  absolute  rest  of  the  part. 
In  large  or  thin-walled  aneurisms  it  is  often  desirable  to  perform  the 
operation  in  two  stages:  first,  ligation  of  the  main  artery  above  the 
aneurism  to  produce  clotting  within  the  sac  and  diminution  in  the 
size  of  the  tumor,  and  at  a  later  period  to  remove  the  sac.  This 
method  is  undoubtedly  safer  than  to  perform  the  operation  while 


256  SURGERY  OF  PERICARDIUM  AND  HEART 

the  tumor  is  tense  and  liable  to  rupture,  and  when  all  the  connecting 
arterial  branches  are  open  and  pulsating. 

Proximal  ligature  is  perhaps  the  method  most  generally  employed 
at  the  present  time  for  the  cure  of  aneurisms.  Ligature  just  above 
the  tumor  with  a  view  to  cutting  off  the  circulation  entirely,  the  method 
of  Anel  (Fig.  131),  is  often  employed;  but  when  possible  ligature  at 
some  distance  above  the  tumor  (Fig.  132),  the  method  of  Hunter,  is  to 
be  preferred,  as  in  this  operation  the  circulation  is  rarely  completely 
arrested  and  the  danger  of  immediate  gangrene  is  less.  Moreover, 
the  artery  at  this  distance  above  the  aneurism  is  less  likely  to  be 
diseased  and  secondary  hemorrhage  is  thereby  avoided.  The  effect 
of  proximal  ligature  upon  an  aneurism  is  the  same  as  compression  of  the 
artery;  the  blood  current  is  either  completely  arrested  or  the  flow  very 
much  diminished.  In  the  former  instance  a  red  clot  forms  at  once 
in  the  sac,  in  the  latter  a  laminated  fibrinous  clot  forms  slowly  and 
eventually  fills  the  cavity.  In  either  case  pulsation  ceases  in  the  tumor; 
it  becomes  firmer  and  gradually  diminishes  in  size.  Halsted  has 
recently  advocated  partial  obliteration  of  the  lumen  of  the  vessel  by 
means  of  flat  metal  bands,  which  often  can  be  removed  at  a  later 
period.  The  nutrition  of  the  parts  supplied  by  the  artery  will  depend 
upon  the  possibilities  of  the  collateral  circulation  and  the  degree 
to  which  the  anastomosing  vessels  have  been  dilated  by  the  obstruction 
caused  by  the  aneurism.  Generally  the  pulse  below  the  tumor  is 
immediately  obliterated,  the  parts  become  anemic  and  cool,  and 
sensation  may  be  impaired.  The  circulation,  however,  is  gradually 
restored,  the  parts  become  warmer,  and  the  capillary  circulation  more 
active,  as  evidenced  by  a  more  rapid  return  of  the  normal  pink  color 
of  the  nail  or  extremity  of  the  finger  or  toe  after  pressure,  and  a  feeble 
pulsation  can  be  felt  in  the  distal  branches.  When  the  collateral 
circulation  is  insufficient,  the  part  remains  cold  and  lifeless,  and 
gangrene,  generally  of  the  moist  variety,  develops. 

Distal  Ligature. — Proximal  ligature  is  often  impossible  on  account 
of  the  situation  of  the  aneurism  or  its  nearness  to  an  important  trunk. 
In  these  instances  distal  ligature  is  resorted  to  with  a  view  to  arresting 
the  circulation  and  forming  a  clot  within  the  sac.  The  method  is 
inferior  to  the  proximal  ligature,  and  should  only  be  employed  when 
proximal  ligature  is  impossible.  Two  methods  are  in  use:  ligature 
of  the  main  trunk  beyond  the  tumor,  and  ligature  of  one  or  more 
branches  issuing  from  the  main  trunk.  The  former  is  known  as  the 
method  of  Brasdor  (Fig.  133);  the  latter,  as  that  of  Wardrop  (Fig. 
134). 

After  any  operation  in  which  the  main  arterial  trunk  of  an  extremity 
is  ligated,  the  limb  should  be  wrapped  in  cotton  batting  and  bandaged 
without  pressure,  external  heat  applied,  and  the  limb  elevated  to 
favor  return  venous  circulation.  If  gangrene  appears,  amputation 
should  be  resorted  to,  generally  above  the   point  of   ligature. 

The  most  recent  method  of  treating  aneurisms,  and  on  the  whole, 


DISEASES  OF   THE  BLOODVESSELS 


257 


Fig.   133.— Distal  ligature.      (Brasdor.) 


Fig.   134. — Distal  ligature.      (Warclrop.) 


Fig.  135. — Shows  the  orifices  in  the  aneurismal  sac  in  process  of  obliteration  by 
suture.  The  first  plane  of  sutures  may  be  made  with  fine  silk,  but  chromicized  catgut 
is  preferable.  The  sutures  are  applied  very  much  like  Lembert  sutures  in  intestinal 
work;  the  first  plane  of  sutures  should  be  sufficient  to  secure  complete  hemostasis. 
The  orifice  of  the  collateral  vessel  on  the  left  upper  side  of  the  sac  is  shown  closed  by 
three  continuous  sutures. 

17 


258  SURGERY  OF  PERICARDIUM  AND  HEART 

perhaps  the  best  and  safest,  is  that  suggested  by  Matas,  in  1888,  to 
which  he  applied  the  term  endo-aneurismorrhaphy. 

Recognizing  the  ready  adhesion  of  sutured  serous  surfaces,  he  advises, 
after  compression  of  the  main  supplying  arterial  trunk,  incision  into 
the  aneurismal  tumor,  removal  of  the  clots  and  fibrin,  and  closure  of  the 
arterial  orifices  by  sutures  so  placed  as  to  insure  broad  approximation 
of  the  margins  of  the  openings  (Fig.  135).  In  sacculated  aneurisms 
he  closes  the  single  orifice  of  communication  between  the  artery  and 
aneurismal  sac  and  thus  restores  the  main  vessel  (Fig.  136).  In  certain 
fusiform  aneurisms  he  constructs  a  new  channel  by  suturing  the  walls 


Fig.  136. — Shows  the  sac  of  a  sacculated  aneurism  opened.  The  dotted  lines  indi- 
cate the  position  and  relations  of  the  main  artery  to  the  sac  and  to  the  orifice  of  com- 
munication. The  object  of  the  operation  in  this  case  is  to  close  the  orifice  of  communi- 
cation without  obliterating  the  main  artery.  The  closure  of  the  orifice  with  continued 
suture  is  shown  in  the  figure. 

of  the  sac  over  a  rubber  catheter,  in  the  same  manner  as  the  Witzel 
method  of  gastrostomy  is  carried  out,  removing  the  catheter,  however, 
before  the  last  suture  is  tied  (Fig.  137).  After  all  of  these  procedures 
he  obliterates  the  remaining  portion  of  the  aneurismal  cavity  by  closely 
approximating  its  walls  by  suture.  After  this  is  accomplished,  the 
wound  is  tightly  closed  and  an  aseptic  dressing  applied.  He  claims 
that  this  method  is  safer  than  the  older  procedures,  the  wounds  heal 
more  promptly,  and  in  some  instances  the  artery  is  restored  to  its 
original  dimensions.  Recently  Matas  has  reported  a  series  of  110 
cases  thus  treated  with  a  mortality  of  only  1.8  per  cent,  and  3.6  per 
cent,  of  subsequent  gangrene. 


DISEASES  OF  THE  BLOODVESSELS 


259 


Other  methods  of  treatment  looking  to  the  formation  of  a  clot  or 
fibrinous  deposit  within  the  sac  of  an  aneurism  have  been  suggested 
from  time  to  time  and  practised  with  varying  degrees  of  success. 

Acupuncture. — Introducing  a  number  of  needles  into  the  sac  of 
an  aneurism  and  allowing  them  to  remain  ten  or  twelve  hours  has 
occasionally  been  followed  by  the  formation  of  firm  coagulation  within 
the  sac,  and  cures  have  been  reported. 

The  introduction  of  large  masses  of  silver,  gold,  platinum,  or  steel  wire 
into  an  aneurism  through  a  minute  canula  has  been  successfully 
employed  in  a  number  of  cases. 


Fig.  137. — Shows  method  of  creating  a  new  channel  in  a  fusiform  aneurism.  The 
sutures  are  nearly  all  tied,  and  the  new  channel  is  completed  except  in  the  centre.  The 
two  upper  sutures  are  hooked  and  pulled  out  of  the  way  while  still  in  position,  and  the 
catheter  withdrawn. 


Galvanopuncture,  by  introducing  two  fine  insulated  steel  needles 
into  an  aneurismal  sac  and  allowing  a  galvanic  current  from  ten  to 
twelve  cells  to  pass  through  the  contained  blood,  will  often  cause  the 
rapid  formation  of  a  firm  fibrinous  mass. 

A  combination  of  these  two  last  methods  has  of  late  been  quite 
extensively  employed.  Willard  has  recently  reported  24  cases  treated 
in  this  manner,  10  of  which  were  positively  benefited,  and  all  were 
apparently  rendered  more  comfortable  by  the  treatment.  The  method 
consists  in  introducing- through  a  fine  insulated  canula  from  15  to  20 
feet  of  fine  silver  or  gold  wire  previously  wound  upon  a  spool  to  insure 


260  SURGERY  OF  PERICARDIUM  AND  HEART 

its  curling  up  within  the  sac,  and  to  pass  through  this  for  one  hour  a 
current  of  from  5  to  SO  milliamperes,  the  positive  pole  being  connected 
with  the  wire,  the  negative  applied  by  means  of  a  sponge  to  the  back 
of  the  patient. 

INJURIES  AND  DISEASES   OF  THE  VEINS. 

Injuries  of  the  veins  and  their  treatment  have  been  considered 
under  Hemorrhage,  in  Chapter  VII. 

Phlebitis. — Phlebitis  is  an  inflammation  of  one  or  more  coats  of  a 
vein.  Two  varieties  are  described,  the  plastic  or  non-suppurative, 
and  the  infective  or  suppurative  variety.  Plastic  phlebitis  is  said  to 
result  from  trauma,  gout,  rheumatism,  and  other  debilitating  consti- 
tutional conditions.  It  is  probably  due  in  the  majority  of  cases  to  the 
action  of  pathogenic  micro-organisms,  the  virulence  of  which  is  not 
sufficient  to  excite  the  ordinary  evidences  of  inflammation.  The 
intima  of  the  vein  becomes  thickened  or  eroded,  a  thrombus  forms 
at  the  site  of  the  lesion  which  eventually  fills  the  lumen  of  the  vein 
and  many  extend  upward  or  downward  for  a  considerable  distance. 
This  condition  of  thrombosis,  when  it  occurs  in  a  large  venous  trunk, 
greatly  interferes  with  the  return  venous  circulation  and  gives  rise  to 
edema  of  the  extremity  or  part  below  the  lesion.  The  thrombus  may 
become  organized  and  converted  into  firm  connective  tissue  which 
permanently  plugs  the  vessel;  it  may  become  calcified  (phlebolith) ; 
or  it  may  become  canalized  by  the  dilatation  of  the  new  capillaries 
formed  within  the  organized  thrombus  or  a  coalescence  of  small 
spaces  or  vacuoles  which  form  during  contraction  of  the  clot.  If  the 
lumen  is  restored,  the  circulation  goes  on  as  before;  if  it  is  permanently 
occluded,  the  free  venous  anastomosis  soon  forms  compensatory 
channels. 

Infective  or  Suppurative  Phlebitis. — This  practically  always  results 
from  some  acute  inflammatory  process  in  the  neighborhood  of  the  vein, 
generally  a  cellulitis  or  infected  wound.  The  process  may  begin  from 
without  and  involve  all  the  coats  of  the  vein,  or  from  within  by  infection 
conveyed  through  the  blood.  There  is  usually  a  marked  round-cell 
infiltration  of  the  entire  vein.  A  thrombus  forms  as  in  plastic  phlebitis, 
but  soon  breaks  down,  forming  a  purulent  mass,  which  may  give  rise 
to  local  abscesses  along  the  course  of  the  vein,  or  infective  thrombi 
which  are  carried  to  various  parts  of  the  body  and  by  their  lodgement 
give  rise  to  secondary  suppurative  lesions  (pyemia). 

Diagnosis. — The  symptoms  of  plastic  phlebitis  are  simply  a  thicken- 
ing of  the  vein  and  a  certain  amount  of  edema  below  the  lesion.  If  the 
vein  is  a  small  one  and  anastomosis  is  free,  edema  may  be  wanting. 
If  the  vein  is  a  large  one,  as  the  femoral,  edema  may  be  marked,  increas- 
ing the  circumference  of  the  limb  to  double  its  normal  size.  This 
continues  for  from  two  to  six  weeks  and  then  gradually  subsides. 
There  is,  as  a  rule,  no  pain,  only  a  feeling  of  numbness  and  weight. 


INJURIES  AND  DISEASES  OF  THE  VEINS  261 

Fever  may  be  present,  but  is  usually  of  moderate  degree.     In  the 

suppurative  variety  the  vein  and  perivascular  tissues  become  thick- 
ened, hot  and  tender,  the  overlying  skin  reddened  and  edematous. 
Fever  is  present,  often  accompanied  by  chills  and  sweats.  If  a  large 
trunk  is  involved,  edema  may  occur  as  in  the  plastic  variety.  Later, 
suppuration  occurs  in  several  places  along  the  vein,  or  the  symptoms 
of  general  sepsis  with  metastatic  abscesses  develop. 

Treatment. — In  the  plastic  variety  with  thrombosis  of  a  large  trunk 
and  edema,  absolute  rest  in  bed  should  be  advised,  with  slight  elevation 
of  the  limb  to  favor  return  venous  circulation  and  the  application  of  a 
moderate  degree  of  heat  by  means  of  well-protected  hot-water  bags. 
Active  movements  of  the  extremity,  massage,  or  any  handling  of  the 
region  of  the  thrombosed  vein,  should  be  avoided  on  account  of  the 
danger  of  dislodging  a  portion  of  the  clot.  In  the  infected  variety 
wet  dressings  should  be  applied  to  the  infected  region  and  the  abscesses 
opened  and  freely  drained.  It  is  often  advisable  in  the  early  stages  of 
a  septic  phlebitis  to  ligate  the  vein  above  and  below  the  thrombus, 
open  and  remove  the  infected  mass.  If  this  can  be  carried  out  early, 
metastasis  and  general  sepsis  often  may  be  avoided. 

Varicose  Veins. — A  permanently  dilated,  lengthened,  and  thickened 
condition  of  the  veins  occurs  in  various  parts  of  the  body,  and  con- 
stitutes the  condition  knowm  as  varicose  veins.  The  predisposing 
cause  of  this  pathologic  dilatation  and  enlargement  is  either  increased 
blood-pressure  or  diminished  resistance  of  the  tissues  of  the  vein, 
or  both  combined.  The  exciting  cause  is  generally  some  extra  muscu- 
lar strain  frequently  repeated,  or  an  obstruction  in  the  larger  trunks, 
as  from  thrombosis,  the  pressure  of  tumors,  or  in  the  case  of  the 
lowrer  extremity,  the  weight  of  the  pregnant  uterus,  or  the  constriction 
of  elastic  garters,  especially  when  worn  belowr  the  knee. 

Another,  and  in  the  writer's  opinion  the  most  important  etiologic 
factor  in  varicose  veins  of  the  leg,  is  the  habit  necessitated  by  certain 
occupations  of  constant  standing  without  the  opportunity  of  muscular 
exercise. 

The  usual  situations  in  which  varicose  veins  are  found  are  the 
lower  extremities,  especially  below  the  knees,  the  mucous  membrane 
of  the  anus  and  lower  portion  of  the  rectum  (hemorrhoids),  and  in  the 
tissues  of  the  scrotum  (varicocele) . 

Varicose  Veins  of  the  Leg. — A  dilated  and  thickened  condition  of 
the  subcutaneous  veins  of  the  lower  leg  is  of  common  occurrence, 
chiefly  in  middle-aged  individuals  whose  occupations  require  constant 
standing.  The  dilated  veins  are  found,  as  a  rule,  to  be  the  tributaries 
of  the  internal  saphenous  vein,  which  may  also  partake  of  the  process 
(Fig.  138).  Exceptionally  the  disease  affects  the  external  saphenous 
and  its  branches  (Fig.  139).  In  the  former  instance  the  veins  are 
chiefly  on  the  inner  aspect  of  the  calf,  while  in  the  latter  they  are 
found  on  the  outer  side  and  posteriorly.  All  three  coats  of  the  vein 
are  thickened.  The  walls  are  rigid  and  often  calcified.  When  cut, 
the  vessel  remains  open  like  an  artery. 


262 


SURGERY  OF  PERICARDIUM  AND  HEART 


The  venous  system  in  the  leg  consists  of  two  portions,  a  deep  and 
superficial  set  of  veins.  The  deep  veins  collect  the  blood  from  the 
muscles  and  empty  into  the  anterior  and  posterior  tibials,  the  peroneal, 
popliteal,  and  femoral  trunks.  The  superficial  veins  form  a  network 
of  vessels  in  the  subcutaneous  tissues,  have  a  number  of  direct  con- 
nections with  the  deep  system,  and  eventually  empty  into  the  external 
or  internal  saphenous  vein,  the  former  joining  the  popliteal  at  the  back 
of  the  knee,  the  latter  the  femoral  at  the  saphenous  opening.  During 
rest  most  of  the  blood^from  the  musculature  of  the  lower  extremity 


Fig.  138. — Varicose  veins  of  leg;  internal  saphenous  branches. 

passes  through  the  deep  veins  into  the  femoral.  During  violent 
muscular  exertion  a  large  part  of  the  blood  from  the  muscles  passes 
through  the  unimpeded  vessels  of  the  superficial  set,  which  can  be 
seen  to  dilate  during  the  muscular  effort. 

The  superficial  veins  therefore  act  as  a  compensatory  system, 
capable  at  any  time  of  carrying  most,  if  not  all,  of  the  blood  returning 
from  the  lower  extremity.  Raymond  Russ,  who  has  recently  published 
some  interesting  studies  upon  the  subject,1  calls  attention  to  the  fact 

1  Surgery,  Gynecology  and  Obstetrics,  April,  1908. 


INJURIES  AND  DISEASES  OF  THE  VEINS  2G3 

that,  while  the  exact  situation  of  the  communicating  branches  between 
the  deep  and  superficial  systems  may  vary  in  different  individuals, 
in  general  a  free  anastomosis  exists  about  the  dorsum  of  the  foot 
and  ankle,  at  the  knee,  and  at  one  or  two  points  between  the  ankle 


Fig.  139. — Varicose  veins  of  the  leg;  external  saphenous  branches. 

and  the  knee  where  the  middle  and  upper  perforating  branches  are 
located. 

When,  for  any  reason,  as  congenital  weakness  or  as  a  result  of 
malnutrition  or  disease,  the  walls  of  a  vein  become  so  weakened 
that  it  cannot  withstand  the  extra  strain  of  severe  and  frequently 
repeated  muscular  effort,  pathologic  changes  occur.     At  first  a  com- 


264  SURGERY  OF  PERICARDIUM  AXD  HEART 

pensatory  hypertrophy  takes  place,  which  may  continue  for  a  time 
and  the  functions  of  the  vessel  remain  intact.  At  a  later  period  this 
compensation  is  broken  and  permanent  dilatation  takes  place  with  a 
resulting  incompetency  of  the  valves  which,  in  the  case  of  the  main 
trunk  of  the  internal  saphenous,  gives  an  enormous  increase  in  the 
blood-pressure  in  its  lower  branches  when  the  patient  is  standing. 
from  the  weight  of  the  unsupported  column  of  blcod. 

Trendelenburg  long  ago  called  attention  to  the  fact  that,  as  the 
inferior  cava,  iliac,  and  femoral  veins  have  no  valves,  and  that  if  the 
valves  of  the  internal  saphenous  become  incompetent,  the  weight  of 
the  column  of  blood  from  the  right  heart  to  the  lower  subcutaneous 
vein  of  the  leg  is  enormous,  and  will  invariably  cause  dilatation  of  the 
inferior  tributaries. 

Compensatory  hypertrophy  of  the  subcutaneous  veins  of  the  leg 
and  thigh  is  occasionally  seen  as  a  result  of  femoral  or  iliac  thrombosis. 
In  these  cases  the  main  trunk  of  the  internal  saphenous  is  more  notice- 
ably enlarged  than  the  lcwer  branches,  and  the  superficial  epigastric 
and  circumflex  iliac  partake  in  the  process,  often  forming  large  trunks 
passing  from  the  saphenous  opening  to  the  pubis  and  abdomen. 

It  is  obvious  that  these  vessels  should  never  be  disturbed,  as  the 
condition  is  a  compensatory  anastomosis  around  the  obliterated 
femoral  trunk. 

The  question  of  involvement  of  the  deeper  veins  of  the  leg  is  an 
important  one,  and  has  been  investigated  by  Gay,  Quenu,  and  others. 
From  their  investigations  it  is  probable  that  it  occurs  in  about  one-half 
of  the  cases.  Not  infrequently  it  occurs  with  but  little  evidence  of 
disease  in  the  superficial  group. 

Symptoms. — A  moderate  degree  of  varicosity  of  the  superficial 
veins  of  the  lower  leg  causes,  as  a  rule,  no  discomfort.  When  the 
valves  of  the  saphenous  become  incompetent,  however,  the  patient 
experiences  a  sense  of  weight  and  fulness  in  the  leg  and  foot,  which 
is  promptly  relieved  on  assuming  the  recumbent  posture.  In  more 
advanced  cases  pain  is  experienced  on  prolonged  standing,  and  edema 
of  the  lower  leg  and  foot  may  be  present.  Thickening,  bluish  discolora- 
tion, and  pigmentation  of  the  skin  may  occur  from  chronic  passive 
hyperemia,  which  also  favors  the  formation  of  ulcers  and  eczema. 
These  changes,  as  a  rule,  are  more  marked  in  the  lower  half  of  the  leg. 
This  fact  serves  to  distinguish  the  varicose  from  the  syphilitic  ulcer 
(Fig.  140).  The  latter,  while  it  may  occur  in  any  part  of  the  leg,  is  more 
frequently  observed  in  the  upper  segment.  Atrophy  of  the  skin  over 
a  mass  of  varicose  veins  is  occasionally  present  and  predisposed  to 
rupture  from  some  slight  trauma.  The  hemorrhage  in  such  cases  is 
often  alarming,  both  from  the  large  size  of  the  vessel  and  from  the  fact 
that  the  blood  flows  from  both  upper  and  lower  segments  of  the  vein. 

Where  the  deeper  veins  are  involved  the  pain  and  discomfort  are, 
as  a  rule,  more  marked  than  in  the  superficial  variety.  In  these 
cases    there    is    often    more    edema    on    standing.     Trendelenburg's 


INJURIES  AND  DISEASES  OF   THE   VEINS  265 

sign  is  frequently  absent  and  the  visible  dilatations  arc  more  marked 
at  the  points  where  the  deep  anastomosing  veins  join  the  superficial 
system. 

Diagnosis.  The  diagnosis  of  varicose  veins  of  the  leg  often  can 
be  made  by  inspection.  When  the  patient  is  standing  large,  tortuous, 
bluish  cords  can  be  seen  coursing  over  the  calf  of  the  leg  and  often 
extending  upward  along  the  inner  side  of  the  thigh  to  the  region  of 
the  saphenous  opening.  To  determine  the  question  of  competency  of 
the  valves  Trendelenburg's  test  should  be  applied.  The  patient  is 
placed  upon  his  back  and  the  leg  elevated  to  allow  the  veins  to  become 
empty.     The  finger  is  then  firmly  placed  over  the  upper  portion  of 


Fig.  140. — Varicose  leg  ulcer. 

the  long  saphenous  vein,  just  below  the  saphenous  opening,  and  the 
patient  instructed  to  stand  erect.  The  lower  branches  will  gradually 
refill  from  the  deeper  veins.  If,  however,  the  compression  of  the 
saphenous  is  removed,  the  blood  current  generally  can  be  seen  to  course 
down  the  main  trunk  and  rapidly  distend  the  branches.  If  the  fingers 
are  placed  over  the  lower  portion  of  the  trunk,  the  downward  rush 
of  the  blood  imparts  to  the  examining  fingers  a  distinct  thrill.  In 
cases  of  marked  obesity,  and  occasionally  in  cases  of  moderate  dilata- 
tion of  the  vein,  the  descending  current  of  blood  cannot  be  seen,  but 
if  the  valves  are  incompetent  it  can  always  be  felt. 

Treatment. — A  tendency  to  varicose  veins  of  the  leg  sometimes 
can  be  arrested  in  the  early  stages  by  wearing  an  elastic  stocking 


266  SURGERY  OF  PERICARDIUM  AND  HEART 

or  by  the  use  of  a  rubber  or  flannel  bandage.  Cardiac  lesions  causing 
passive  venous  congestion  should  be  corrected  and  the  wearing  of 
tight  garters  avoided.  Regarding  operative  treatment,  considerable 
care  should  be  exercised  in  the  selection  of  cases.  For  instance,  it 
would  be  manifestly  absurd  to  ligate  or  remove  the  dilated  superficial 
veins  in  a  case  of  femoral  or  iliac  thrombosis.  Operation  is  likewise 
rarely  productive  of  good  in  those  comparatively  rare  cases  where  the 
chief  lesion  is  located  in  the  deep  veins  of  the  leg,  the  superficial  group 
being  dilated  only  in  the  region  of  the  anastomosing  channels. 

Where  there  is  valvular  incompetency,  however,  and  evident 
involvement  of  the  internal  saphenous  trunk,  operation  is  to  be 
recommended. 

A  limited  removal  of  the  veins  is  also  indicated  where  they  are 
near  the  surface  and  likely  to  rupture. 

Three  operative  methods  are  at  present  employed  in  this  condition: 
Complete  removal  of  the  internal  saphenous  trunk,  either  by  open 
excision  (Madelung)  or  by  the  subcutaneous  method  (Mayo) ;  multiple 
excisions  of  the  main  trunk  and  chief  branches;  and  the  Trendelenburg 
operation. 


Fig.  141. — Mavo's  varicose  vein  enucleator. 


Excision  of  the  main  trunk  of  the  saphenous  is  best  accomplished 
by  means  of  the  Mayo  ring  enucleator  (Fig.  141 ).  The  upper  segment 
of  the  vein  is  exposed  by  a  short  incision,  the  vein  doubly  ligated,  and 
divided.  The  lower  portion  of  the  vein  is  threaded  through  the  ring 
of  the  enucleator  and  held  lightly  by  the  left  hand  of  the  operator. 
^Yith  the  right  the  enucleator  is  pushed  downward,  severing  the  vein 
from  its  branches,  until  about  eight  or  ten  inches  are  thus  freed. 
The  ring  is  then  pressed  firmly  against  the  skin  and  a  small  button-hole 
incision  made,  through  which  the  freed  extremity  of  the  vein  is  drawn. 
The  enucleator  is  next  removed  from  the  original  wound  and  the  same 
procedure  repeated  through  the  second  incision.  In  this  manner  the 
entire  trunk  of  the  saphenous  vein  often  can  be  removed  through 
three  or  four  insignificant  incisions.  The  torn  branches  do  not,  as  a 
rule,  bleed  much,  and  the  flow  is  easily  controlled  by  gentle  pressure. 
This  method  is  the  ideal  one,  and  in  the  writer's  experience  can  be 
carried  out  in  perhaps  one-half  of  the  cases  which  apply  for  treatment. 
In  the  others  it  is  impossible  to  remove  the  vein  in  this  manner  on 
account  of  its  friability  or  the  presence  of  periphlebitis  or  calcareous 
deposits.  It  occasionally  happens  that  the  upper  portion  of  the  vein 
can  be  removed  by  the  enucleator  and  the  lower  portion  by  multiple 
excisions.     One  should  strive  to  remove  the  greatest  amount  of  the 


INJURIES  AND  DISEASES  OF  THE  VEINS  267 

pathologic  vein  through  the  smallest  amount  of  incision,  as  long 
incisions,  especially  in  the  edematous  tissues  of  the  lower  leg,  are  very 
likely  to  become  infected. 

In  a  large  number  of  cases  the  method  by  multiple  incisions  will 
be  indicated.  In  this  an  incision  should  be  made  over  the  highest 
point  of  the  diseased  vessel,  the  vein  isolated,  doubly  ligated,  and  a 
small  section  removed.  Incisions  should  then  be  made  over  the  most 
prominent  masses  lower  down,  the  vessel  excised,  the  various  branches 
and  free  extremities  of  the  vein  ligated,  and  the  cutaneous  wound 
united.  The  Trendelenburg  method  consists  in  applying  an  Esmarch 
bandage  to  the  entire  limb,  then  removing  a  small  section  of  the 
internal  saphenous  vein  near  the  saphenous  opening,  and  keeping 
the  patient  in  bed  until  the  wound  is  healed,  the  theory  of  its  action 
being  that  it  removes  the  pressure  from  the  subcutaneous  veins  of  the 
leg,  which  gradually  regain  their  tone  and  diminish  in  size.  This 
method  of  treatment  is  undoubtedly  efficacious  when  the  disease  is 
limited  to  the  internal  saphenous  system,  and  in  the  early  stages  of  the 
malady  before  the  walls  of  the  dilated  veins  have  become  permanently 
thickened.  Treatment  of  varicose  veins  by  injection  of  coagulating 
agents  into  the  vein  or  by  acupressure  pins  is  not  to  be  recommended. 

Nevus,  or  Venous  Angioma. — This  affection  consists  in  a  mass  of 
dilated  capillaries  or  veins  situated  in  the  skin  or  subcutaneous  tissues. 
The  disease  is  generally  congenital,  although  it  is  apt  to  spread  and  is 
sometimes  first  noticed  at  a  later  period  of  life.  When  the  disease  is 
limited  to  the  capillaries  it  appears  as  a  small  red  or  blue  discoloration 
of  the  skin  which  disappears  on  pressure  and  quickly  returns  when  the 
pressure  is  removed.  Occasionally  large  areas  of  the  skin  are  involved, 
making  the  so-called  "port-wine"  or  "birth"  marks.  If  the  smaller 
veins  are  involved  in  the  process,  the  disease  appears  as  an  elevated, 
soft,  spongy  mass  of  irregular  outline,  of  bluish  or  purplish  tint, 
compressible,  and  rendered  more  prominent  if  on  the  face  or  neck  by 
crying,  coughing,  or  sneezing.  When  situated  wholly  in  the  sub- 
cutaneous tissue  the  discoloration  may  be  slight,  only  a  dusky  hue 
being  noticeable  on  the  surface  of  the  mass.  In  rare  instances  the 
disease  is  associated  with  an  increase  in  the  fatty  tissue,  making  a 
mixed  growth — nevoliporna. 

Treatment. — When  possible,  complete  excision  is  to  be  recommended 
in  the  larger  venous  angiomata,  with  arrest  of  bleeding  and  primary 
closure  of  the  wound.  In  the  smaller  nevi  the  application  of  the 
Paquelin  cautery  point  or  of  red-hot  needles  will  often  bring  about  a 
cure.  Electrolysis  has  been  successful  in  small  angiomata  and  in 
port-wine  marks  of  moderate  extent.  The  method  of  its  application 
is  to  introduce  two  insulated  needles  into  the  tumor  some  little  distance 
apart  and  to  apply  through  them  the  galvanic  current  until  the  tissues 
become  hardened  and  white.  Several  applications  are  often  necessary. 
The  resulting  scar  is  insignificant.  Subcutaneous  cauterization,  either 
by  means  of  Blake's  platinum-pointed  cautery  needles,  which  are  thrust 


268  SURGERY  OF  PERICARDIUM  AND  HEART 

into  the  tumor  from  opposite  sides,  and  rendered  red  hot  by  contact 
of  the  points,  which  completes  the  electric  circuit;  or  by  the  sub- 
cutaneous injection  of  boiling  water — as  recommended  by  Wyeth— 
is  being  largely  employed  at  present  with  good  results.  Recently 
Charles  T.  Dade  has  called  attention  to  a  new  method  of  treating 
angiomata  which,  in  the  smaller  varieties,  bids  fair  to  supersede  all 
others.  His  method  consists  in  freezing  the  part  by  direct  application 
of  liquid  air  by  means  of  a  blunt  cotton  swab.  Freezing  the  part 
with  a  pencil  made  of  carbon  dioxide  snow  is  also  efficacious.  In  the 
smaller  nevi  only  one  application  is  necessary;  in  those  of  larger  extent 
two  or  three  may  be  required.  The  application  causes  only  moderate 
pain  and  the  resulting  scar  is  thin  and  pliable.  The  use  of  the  sub- 
cutaneous ligature  was  formerly  much  employed  in  the  treatment 
of  cutaneous  angiomata,  also  the  use  of  pure  nitric  acid.  Both  of  these 
methods,  however,  have  been  practically  abandoned. 


Y 


Fig.  142. — Congenital  venous  nevus.     (Halloway.) 

LIGATION  OF  ARTERIES  IN  CONTINUITY. 

Ligation  of  arteries  in  continuity  is  required  for  the  control  of 
hemorrhage  when  the  bleeding  point  is  inaccessible  or  the  vessels 
diseased.  It  is  also  required  to  arrest  the  flow  of  blood  through  an 
aneurism,  or  as  a  preliminary  procedure  in  amputations  and  other 
major  operations  when  hemorrhage  is  difficult  to  control. 

The  instruments  required  for  this  operation  are  a  scalpel,  two 
toothed  forceps,  two  retractors,  an  aneurism-needle,  scissors,  artery- 
clamps,  needles,  and  a  needle-holder. 

The  materials  used  for  ligature  are  chromicized  catgut,  chromicized 
kangaroo  tendon,  braided  or  floss  silk. 

The  patient  should  be  placed  in  such  a  position  as  to  give  the  best 
exposure  of  the  part,  the  artery  should  be  accurately  located  by 
anatomic  landmarks,  and  the  tissues  divided,  layer  by  layer,  until  the 
vessel  is  reached.  When  possible,  muscles,  nerves,  and  veins  should 
be  retracted  rather  than  divided,  and  layers  of  fascia,  intermuscular 
septa,  and  areolar  tissue  cut  rather  than  torn.     Veins  which  cannot  be 


LIGATIOX  OF   ARTERIES  IS    COXTI.X CITY 


269 


retracted  should  be  divided  between  two  ligatures.  When  the  sheath 
of  the  artery  is  freely  exposed,  it  should  be  grasped  and  raised  in  a 
transverse  fold  by  two  toothed  forceps,  then  carefully  opened  by 
scissors  or  the  point  of  the  scalpel,  the  back  of  which  is  directed  toward 
the  artery.  When  the  sheath  is  freely  open  the  artery  should  be 
separated  from  it  and  the  aneurism-needle  (Fig.  143)  passed  around  the 
vessel,  threaded  with  the  ligature,  and  carefully  withdrawn  (Fig.  144). 
The  ligature  should  then  be  tied  snugly  with  a  reef  or  surgeon's  knot, 
the  former  in  superficial  vessels,  the  latter  when  the  vessel  lies  deeply 
and  when  accidental  slipping  of  the  knot  cannot  be  readily  appreciated. 
It  was  formerly  supposed  that  the  ligature  should  be  tied  with  sufficient 
force  to  rupture  the  inner  coat  of  the  vessel,  but  the  modern  view  is 
that  equally  good  results  can  be  obtained  by  simply  drawing  the  walls 


Fig.  143. — Aneurism-neeclle. 


Fig.  144. — A.  opening  sheath;   B,  passing  ligature 
around  the  vessel;    C,  tying  the  artery. 


together  without  rupture  of  any  of  the  coats.  The  latter  method  is 
less  likely  to  be  followed  by  secondary  hemorrhage.  Some  surgeons 
advise  double  ligature  and  dividing  the  artery  between  the  two  knots, 
for  the  reason  that  the  arteries  are  elastic  tubes,  and  are  always,  under 
normal  conditions,  subject  to  a  certain  amount  of  tension,  as  shewn 
by  prompt  retraction  of  their  divided  ends  when  cut.  This  tension 
favors  rupture  of  the  vessel  at  a  point  weakened  by  the  application 
of  a  ligature.  While  these  reasons  are  theoretically  correct,  this 
accident  practically  never  occurs  in  aseptic  wounds  when  ordinary 
care  is  used  in  the  application  of  a  ligature  to  a  healthy  vessel.  After 
the  ligature  is  tied  and  cut,  the  wound  should  be  closed  in  the  usual 
manner  and  an  aseptic  dressing  applied.  When  the  main  arterial 
trunk  of  a  limb  has  been  ligated,  the  extremity  should  be  wrapped  in 
cotton-wool  and  slightly  elevated  to  favor  return  venous  circulation. 


270  SURGERY  OF  PERICARDIUM  AND  HEART 

A  good  deal  has  been  written  in  the  older  text-books  about  the 
introduction  of  the  aneurism-needle— that  it  always  should  be  carried 
around  the  artery  in  a  direction  away  from  the  most  important  neigh- 
boring structure.  The  rule  is  a  good  one,  and  should  be  followed 
under  ordinary  circumstances;  but  many  other  factors  may  influence 
the  surgeon  at  the  time  of  operation.  In  clean,  dry  wounds  in  which 
the  structures  are  freely  exposed,  it  makes  little  or  no  difference  in 
which  direction  the  needle  is  passed. 

It  is  well  to  remember  that  all  the  arteries  of  the  upper  extremity 
and  all  below  the  knee  in  the  lower  extremity  are  accompanied  by 
two  veins,  known  as  venae  comites.  The  arteries  of  the  head  and 
neck  except  the  lingual,  the  arteries  of  the  thigh,  and  most  of  the 
arteries  supplying  the  thoracic  and  abdominal  viscera,  have  a  single 
accompanying  vein.  Above  the  diaphragm  all  important  venous 
trunks  which  accompany  the  arteries,  when  not  in  the  same  plane, 
lie  above  the  arteries;  below  the  diaphragm  the  veins  not  lying  in  the 
same  plane  lie  below  the  arteries,  except  the  renal. 

Innominate  Artery.  —  The  innominate  artery  is  exposed  by  an 
incision  along  the  inner  border  of  the  lower  third  of  the  sternomastoid 
muscle,  extending  one  inch  below  the  sternoclavicular  articulation. 
The  superficial  fascia  and  platysma  are  divided,  and  the  anterior 
jugular  vein  secured  between  two  ligatures  and  cut.  The  deep  cervical 
fascia  is  split  and  the  attachments  of  the  sternomastoid,  sternohyoid, 
and  sternothyroid  muscles  partly  divided,  the  former  drawn  outward 
and  the  two  latter  inward  by  retractors.  The  sheath  of  the  common 
carotid  is  opened  and  the  artery  followed  downward  until  the  trunk 
of  the  innominate  is  reached.  If  the  bifurcation  is  low,  it  will  be  neces- 
sary to  resect  a  portion  of  the  sternum  and  the  sternal  extremity  of  the 
clavicle,  to  secure  enough  space  to  apply  the  ligature  successfully. 
The  innominate  vein  lies  to  the  outer  side  and  above  the  artery. 
Care  should  be  taken  in  passing  the  aneurism-needle  to  avoid  the 
vagus  nerve  and  pleura,  which  also  lie  to  the  outer  side  of  the  artery. 

Carotid  Arteries. — Common  Carotid  Artery. — The  common  carotid 
artery  is  exposed  by  an  incision  along  the  inner  border  of  the  sterno- 
mastoid muscle  on  a  line  extending  from  the  sternoclavicular  articula- 
tion to  a  point  midway  between  the  angle  of  the  jaw  and  the  tip  of  the 
mastoid  process.  The  incision  should  extend  from  a  point  opposite 
the  upper  border  of  the  thyroid  cartilage  to  a  point  just  above  the 
sternoclavicular  joint,  and  should  divide  the  skin,  superficial  fascia, 
platysma,  and  deep  fascia.  A  vein  passing  from  the  anterior  jugular 
to  the  temporofacial  vein  will  be  divided;  also  the  sternomastoid 
branch  of  the  superior  thyroid  artery.  The  sternomastoid  muscle  is 
retracted  outward  with  the  internal  jugular  vein;  the  anterior  belly  of 
the  omohyoid  muscle  crosses  the  incision  about  its  middle,  passing 
from  above  obliquely  downward  and  outward.  The  arter}r  may  be 
tied  either  above  or  below  this  muscle.  It  is  easily  recognized  by 
its  pulsation,  and  also  by  its  relation  to  the  carotid  tubercle  on  the 


LIGATION  OF  ARTERIES  IN  CONTINUITY  271 

transverse  process  of  the  sixth  cervical  vertebra.  The  artery  lies  just 
above  this  tubercle  at  the  point  where  it  is  covered  by  the  omohyoid 
muscle.  By  retracting  the  sternohyoid  and  sternothyroid  muscles 
inward  and  the  omohyoid  upward,  the  sheath  of  the  vessel  will  be 
exposed  in  the  triangle  of  necessity;  by  retracting  the  omohyoid  down- 
ward and  inward  the  upper  portion  may  be  reached  in  the  triangle 
of  election.  As  the  descendens  noni  nerve  lies  on  the  anterior  wall  of 
the  sheath,  this  should  be  opened  on  the  inner  wide.  If  the  needle 
is  passed  around  the  artery  within  the  sheath,  there  is  no  danger  of 
including  the  vagus,  which  lies  behind  it. 

External  Carotid  Artery. — The  external  carotid  artery  is  exposed  by  a 
continuation  upward  of  this  same  incision.  The  artery  begins  at  the 
bifurcation  of  the  common  carotid  opposite  the  upper  border  of  the 
thyroid  cartilage,  and  ends  by  division  into  the  internal  maxillary  and 
temporal,  within  the  parotid  gland.  It  is  crossed  by  the  superior 
thyroid,  lingual,  and  temporofacial  veins,  by  the  hypoglossal  nerve 
and  the  digastric  muscle.  It  is  recognized  by  its  numerous  branches. 
It  is  easily  exposed  and  ligated  just  above  the  origin  of  the  superior 
thyroid  branch  at  a  point  opposite  the  great  cornu  of  the  hyoid  bone. 

Internal  Carotid  Artery. — The  internal  carotid  artery  is  exposed  by 
the  same  incision  as  the  external  carotid.  It  lies  behind  and  a  little 
to  the  outer  side  of  the  external  carotid  and  can  be  brought  into  view 
by  drawing  the  external  well  inward.     It  has  no  branches. 

Superior  Thyroid,  Lingual,  Facial  and  Occipital  Arteries.  —  The 
superior  thyroid,  lingual,  facial,  and  occipital  may  all  be  exposed  and 
ligated  near  their  origins  from  the  external  carotid  through  this  incision. 
The  lingual  is  often  ligated  after  it  passes  beneath  the  hyoglossus 
muscle;  by  exposing  this  muscle  by  retracting:  the  submaxillary  gland 
upward  and  separating  its  fibres  the  artery  will  be  found  midway 
between  the  hypoglossal  nerve  and  digastric  tendon,  running  inward 
parallel  with  the  nerve.  The  facial  artery  may  also  be  exposed  and 
tied  as  it  crosses  the  lower  border  of  the  jaw  just  in  front  of  the  masseter 
muscle.  A  short  horizontal  incision,  including  the  skin,  fascia,  and 
platysma,  will  expose  the  artery  and  vein. 

Temporal  Artery. — The  temporal  artery  may  be  exposed  as  it  crosses 
the  zygoma  just  in  front  of  the  external  auditory  meatus.  It  lies 
beneath  the  skin  and  fascia,  and  is  in  relation  to  the  auriculotemporal 
nerve,  which  should  be  recognized  and  avoided  in  passing  the  ligature. 

Subclavian  Artery. — The  subclavian  artery  can  be  safely  exposed 
and  ligated  in  its  third  portion  or  that  part  which  passes  from  the  outer 
border  of  the  scalenus  anticus  muscle  to  the  lower  border  of  the  first 
rib.  The  patient  should  lie  on  his  back  on  the  table  with  a  sand-bag 
under  the  shoulder;  the  head  should  be  turned  to  the  opposite  side 
and  the  arm  drawn  well  downward.  A  horizontal  incision  three  inches 
in  length  should  be  made  over  the  clavicle,  after  drawing  the  skin  well 
downward  to  avoid  the  external  jugular  vein.  When  the  skin  is 
relaxed  the  incision  will  appear  half  an  inch  or  more  above  the  bone. 


272  SURGERY  OF  PERICARDIUM  AND  HEART 

The  superficial  fascia,  platysma,  and  one  or  two  superficial  veins  will 
he  divided,  also  the  deep  fascia.  If  the  space  between  the  trapezius 
and  sternomastoid  muscles  is  too  narrow,  these  should  be  partly 
divided  at  their  attachment  to  the  clavicle  and  well  retracted.  The 
external  jugular  vein,  and  occasionally  other  large  branches,  should 
be  carefully  retracted  or  divided  between  two  ligatures,  the  omohyoid 
muscle  located  and  drawn  upward.  The  artery  can  be  recognized 
by  its  pulsation,  passing  outward  from  behind  the  scalenus  anticus 
muscle,  lying  on  the  scalenus  medius  and  first  rib.  The  subclavian 
vein  lies  in  front  and  below,  the  brachial  plexus  above  and  to  the  outer 
side.  These  structures  and  the  pleura  should  be  avoided  in  passing 
the  needle. 

Vertebral  Artery. — The  vertebral  artery  may  be  exposed  by  an 
incision  along  the  posterior  border  of  the  lower  half  of  the  sternomastoid 
muscle.  This  incision  includes  the  skin,  superficial  fascia,  platysma, 
and  deep  fascia.  The  sternomastoid  is  retracted  inward,  the  scalenus 
anticus  muscle  recognized,  and  the  space  between  it  and  the  longus 
colli  muscle  cleared.  The  artery  lies  just  below  the  transverse  process 
of  the  sixth  vertebra.  The  vein  lies  anteriorly  and  should  be  retracted. 
The  ligature  occasionally  includes  some  fibres  of  the  sympathetic, 
which  would  be  indicated  by  a  subsequent  contraction  of  the  pupil. 

Inferior  Thyroid  Artery. — The  inferior  thyroid  artery  may  be  ex- 
posed through  the  incision  for  ligature  of  the  common  carotid  in  the 
triangle  of  necessity.  After  the  carotid  sheath  is  exposed,  it  is  retracted 
outward  with  the  sternomastoid  muscle,  the  sternohyoid  and  sterno- 
thyroid muscles  and  the  thyroid  gland  are  drawn  well  inward,  and  on 
the  floor  of  the  space  thus  formed  the  inferior  thyroid  artery  will  be 
seen  passing  inward  just  below  the  transverse  process  of  the  sixth 
cervical  vertebra.  It  should  be  ligated  as  far  outward  as  possible 
to  avoid  the  recurrent  laryngeal  nerve. 

Axillary  Artery. — The  axillary  artery  may  be  ligated  in  its  first  and 
third  portions.  The  first  part  is  exposed  by  an  incision,  horizontal 
or  slightly  curved  upward,  just  below  the  clavicle,  from  the  inner  border 
of  the  deltoid,  to  a  point  near  the  sternoclavicular  articulation.  The 
clavicular  fibres  of  the  pectoralis  major  are  divided  and  the  tendon 
of  the  pectoralis  minor  exposed.  The  costocoracoid  membrane  is 
next  divided  and  the  acromial  thoracic  artery  and  the  cephalic  vein 
followed  downward  to  their  junction  with  the  main  trunks.  The 
artery  can  be  recognized  by  its  pulsation  and  by  its  position  below 
the  cords  of  the  brachial  plexus  and  above  the  vein. 

The  third  portion  of  the  artery  is  exposed  in  the  axilla.  The  arm 
is  held  at  a  right  angle  with  the  body  and  an  incision  three  inches  in 
length  is  made  along  the  course  of  the  artery,  which  can  be  easily 
located  by  its  pulsations.  Division  of  the  skin  and  fascia  will  expose 
the  vein,  which  lies  above  and  to  the  inner  side  of  the  artery.  The 
ulnar  and  internal  cutaneous  nerves  lie  to  the  inner  side  below  the 
vein,  the  musculocutaneous  to  the  outer  side,  and  the  median  just 


LIGATION  OF  ARTERIES  IN  CONTINUITY  '27'.] 

above  the  artery.  These  should  be  retracted,  the  venae  comites 
separated  from  the  artery,  and  a  ligature  applied  below  the  origin  of 
the  circumflex  branehes. 

Brachial  Artery.  — The  brachial  artery  lies  just  beneath  the  skin  and 
fascia  along  the  inner  border  of  the  biceps  muscle,  corresponding  with 
a  line  drawn  from  the  junction  of  the  anterior  and  middle  thirds  of 
the  outlet  of  the  axilla  to  the  middle  of  the  bend  of  the  elbow.  The 
vessel  is  exposed  in  the  middle  of  the  arm  by  an  incision  along  the 
inner  border  of  the  biceps  muscle,  dividing  the  skin  and  fascia.  The 
artery  is  easily  recognized  by  its  pulsations.  The  median  nerve  lies 
upon  the  artery  and  should  be  retracted.  The  sheath  is  next  opened 
and  the  ligature  placed  about  the  vessel,  care  being  taken  to  avoid  the 
vena?  comites.  At  the  bend  of  the  elbow  the  artery  can  be  easily 
exposed  by  a  short  oblique  incision  along  the  inner  side  of  the  biceps 
tendon  parallel  with  the  median  basilic  vein.  The  bicipital  fascia 
is  divided  and  the  artery  with  its  venae  comites  exposed. 

Radial  Artery. — The  radial  artery  may  be  exposed  at  any  part  of  its 
course  in  the  forearm,  or  in  the  tabatiere  between  the  extensor  tendons 
of  the  thumb.  The  line  of  the  artery  extends  from  the  middle  of 
the  bend  of  the  elbow  to  a  point  midway  between  the  tendons  of  the 
flexor  carpi  radialis  and  the  palmaris  longus  at  the  wrist.  In  the  middle 
and  upper  part  of  the  forearm  the  artery  is  reached  by  an  incision 
along  the  line  of  the  vessel.  After  division  of  the  skin  and  fascia 
the  inner  border  of  the  supinator  longus  muscle  is  found  and  retracted 
outward.  This  exposes  the  vessel  and  its  vense  comites.  The  radial 
nerve  lies  to  the  outer  side  of  the  artery.  In  the  lower  third  of  the 
forearm  the  artery  lies  between  the  tendons  of  the  supinator  longus 
and  flexor  capi  radialis,  and  may  be  easily  reached  by  an  incision  which 
exposes  these  structures.  In  the  tabatiere  the  artery  may  be  exposed 
by  an  oblique  incision  in  the  triangular  space  between  the  extensor 
tendons  of  the  thumb.  A  superficial  vein  is  encountered  which  may 
be  retracted  or  divided.  The  artery  lies  immediately  below  the  deep 
fascia. 

Ulnar  Artery. — The  ulnar  artery  can  be  exposed  at  the  bifurcation 
of  the  brachial  by  an  oblique  incision  just  below  the  bend  of  the  elbow 
along  the  upper  border  of  the  pronator  radii  teres  muscle  and  retracting 
the  muscle  inward.  The  artery  is  reached  by  following  the  brachial 
downward.  In  the  middle  of  the  forearm  the  artery  lies  beneath  a 
line  extending  from  the  tip  of  the  internal  condyle  to  the  outer  side 
of  the  pisiform  bone.  An  incision  is  made  along  this  line  dividing 
the  skin  and  superficial  fascia.  The  white  line  of  the  intermuscular 
septum  between  the  flexor  carpi  ulnaris  and  the  flexor  sublimis  digi- 
torum  is  found  and  the  muscles  separated.  The  artery  with  the 
accompanying  vena?  comites  will  be  found  at  the  bottom  of  the  wound. 
The  ulnar  nerve  lies  to  the  inner  side  of  the  artery.  Above  the  wrist 
the  artery  is  easily  reached  by  an  incision  along  the  same  line,  just 
to  the  outer  side  of  the  tendon  of  the  flexor  carpi  ulnaris.  After  the 
18 


274  SURGERY  OF  PERICARDIUM  AND  HEART 

deep  fascia  is  incised  and  the  tendon  of  the  ulnar  flexor  drawn  inward, 
the  artery  is  easily  found  and  ligated.  The  ulnar  nerve  lies  to  the 
ulnar  side  of  the  artery. 

Abdominal  Aorta. — The  abdominal  aorta  has  been  ligated  on  several 
occasions  for  hemorrhage  or  aneurisms  of  its  lower  segment  or  of  the 
iliac  arteries  and  the  procedure  is  still  regarded  by  surgeons  as  a 
justifiable  experiment  in  certain  cases.  The  vessel  may  be  reached 
by  two  routes,  the  abdominal  and  the  retroperitoneal  or  lumbar.  The 
former  is  to  be  preferred,  not  only  on  account  of  the  ease  of  its  perform- 
ance, but  also  for  the  reason  that  the  latter  is  associated  with  grave 
danger  of  sloughing  of  the  colon  from  accidental  injury  to  the  branches 
of  the  inferior  mesenteric  artery.  An  incision  is  made  just  to  the  left 
of  the  median  line  opposite  the  point  selected  for  the  ligature  and 
the  abdominal  cavity  freely  opened.  The  small  intestine  is  drawn 
aside  and  retained  by  gauze  pads.  The  vessel  is  recognized  by  its 
size  and  pulsations.  The  parietal  peritoneum  is  divided  and  the 
aneurism-needle  passed  around  the  artery  in  such  a  maimer  as  to  avoid 
injuring  the  sympathetic  plexus  which  surrounds  the  vessel.  Floss 
silk  or  flat  kangaroo  tendon  should  be  used  for  the  ligature,  and  the 
knot  should  be  drawn  with  only  sufficient  force  to  cause  arrest  of 
the  flow  of  blood,  and  not  to  injure  the  vessel  walls.  In  case  of 
aneurism  a  temporary  ligature  is  indicated,  and  is  not  necessarily 
drawn  sufficiently  tight  to  occlude  the  lumen  of  the  vessel  completely. 

Hiac  Arteries. — Common  Iliac  Artery. — The  common  iliac  artery  may 
be  reached  by  a  transperitoneal  incision  through  the  median  line  or 
along  the  outer  border  of  the  rectus  muscle.  The  intestines  are  packed 
aside  and  the  vessel  easily  recognized  by  its  pulsation.  In  dividing 
the  peritoneum  over  the  vessel  care  should  be  taken  to  avoid  wounding 
the  ureter,  which  crosses  the  vessel  near  its  bifurcation.  The  iliac 
vein  lies  below  and  to  the  right  of  the  artery.  The  Trendelenburg 
posture  is  to  be  recommended  in  this  operation.  The  operation 
generally  employed  to  expose  this  vessel  is  by  the  curved  inguinal 
incision  of  Mott  for  exposing  the  iliac  vessels.  This  incision  begins 
one  inch  above  the  centre  of  Poupart's  ligament,  and  is  carried  upward 
and  outward  in  a  curved  direction,  keeping  about  one  inch  to  the  inner 
side  of  the  ligament  and  the  anterior  superior  spinous  process  of  the 
ilium,  then  carried  upward  and  slightly  inward  toward  the  umbilicus. 
The  incision  is  about  eight  inches  in  length,  and  is  carried  downward 
through  the  various  muscular  layers  and  transversalis  fascia  until  the 
subserous  fat  is  reached.  The  peritoneum  is  then  carefully  separated 
from  the  iliac  muscle  and  retraced  toward  the  median  line  until  the 
psoas  muscle  and  iliac  vessels  are  freely  exposed.  The  ureter  is 
generally  raised  from  the  vessel  with  the  peritoneum.  By  retracting 
the  edges  of  the  wound  a  good  view  of  the  common  and  external 
iliac  vessels  can  be  obtained,  and  a  ligature  can  be  applied  at  any  point. 

Internal  Iliac  Artery. — The  internal  iliac  artery  is  reached  best  by 
means  of  a  transperitoneal  median  incision  below  the  umbilicus,  the 


LIGATION  OF  ARTERIES  IN  CONTINUITY  275 

patient  being  in  the  Trendelenburg  position.  The  artery  can  be 
recognized  by  tracing  it  downward  from  the  common  iliac.  Care 
should  be  taken  to  avoid  wounding  the  ureter  and  the  accompanying 
vein. 

External  Iliac  Artery. — The  external  iliac  artery  can  be  exposed  by 
the  transperitoneal  operation  or  by  the  incision  of  Cooper,  which  is 
practically  the  same  as  the  lower  four  inches  of  the  Mott  incision 
described  above  for  the  common  iliac  artery.  When  the  peritoneum 
is  retracted,  the  artery  is  seen  lying  upon  the  inner  border  of  the  psoas 
muscle.  The  vein  lies  to  the  inner  side  of  the  artery,  and  the  anterior 
crural  nerve  to  the  outer  side,  the  genitocrural  on  the  vessel.  High 
up  it  is  crossed  by  the  vas  deferens,  and  occasionally  by  the  ureter. 
The  writer  has  exposed  the  artery  for  temporary  compression  on 
several  occasions  by  the  intermuscular  method,  following  the  McBurney 
procedure  for  interval  appendectomy  until  the  peritoneum  is  reached, 
then  stripping  it  from  the  iliac  muscle  as  in  the  Cooper  operation. 
The  artery  can  be  exposed  by  this  method  throughout  its  entire  extent 
and  can  be  easily  ligated.  After  ligation  the  tissues  fall  together,  and 
it  is  only  necessary  to  unite  the  aponeurosis  of  the  external  oblique 
and  the  skin. 

Gluteal  Artery. — The  gluteal  artery  may  be  exposed  by  an  incision 
on  a  line  passing  from  the  posterior  superior  spinous  process  of  the 
ilium  to  the  great  trochanter.  The  artery  emerges  from  the  sciatic 
notch  above  the  pyriformis  muscle  opposite  the  junction  of  the  upper 
with  the  middle  third  of  this  line.  The  fibres  of  the  gluteus  maximus 
and  medius  should  be  separated  and  well  retracted.  The  gluteal 
nerve  lies  below  the  artery. 

Sciatic  Artery. — The  sciatic  artery  emerges  from  the  pelvis  below 
the  pyriformis  muscle  with  the  sciatic  nerve  and  internal  pudic  artery, 
at  a  point  opposite  the  junction  of  the  lower  and  middle  thirds  of  a  line 
drawn  from  the  posterior  superior  spinous  process  to  the  tuberosity 
of  the  ischium.  It  can  be  exposed  by  a  perpendicular  or  oblique 
incision. 

Femoral  Artery. — Common  Femoral  Artery. — The  common  femoral 
artery  is  only  about  one  and  one-half  inches  in  length.  Its  position 
and  that  of  the  superficial  femoral  may  be  indicated  by  a  line  drawn 
from  a  point  on  Poupart's  ligament  midway  between  the  anterior 
superior  spinous  process  and  the  symphysis  pubis  to  the  adductor 
tubercle  on  the  inner  condyle  of  the  femur.  The  incision  should  be 
made  along  the  line  beginning  half  an  inch  above  Poupart's  ligament 
and  extending  three  inches  below  that  point.  The  superficial  veins 
should  be  retracted  or  divided,  the  deep  fascia  opened,  the  artery 
recognized  by  its  pulsations,  the  sheath  incised  and  the  needle  passed 
away  from  the  vein,  which  lies  to  the  inner  side  of  the  artery. 

Superficial  Femoral  Artery. — The  superficial  femoral  artery  in 
Scarpa's  triangle  is  exposed  by  a  similar  incision  carried  further 
downward,  and  ligated  in  the  same  manner.     The  superficial  femoral 


276  SURGERY  OF  PERICARDIUM  AND  HEART 

artery  in  Hunter's  canal  is  exposed  by  an  incision  three  or  four  inches 
in  length  along  the  line  of  the  artery  in  the  middle  third  of  the  thigh. 
The  deep  fascia  is  incised  and  the  sartorius  muscle  recognized  and 
retracted  inward.  The  roof  of  the  aponeurotic  canal  is  exposed  by 
this  retraction  and  is  opened  on  a  director.  The  artery  is  easily 
felt  and  separated  from  the  vein,  which  lies  behind  and  to  the  outer 
side  of  it.  The  long  saphenous  nerve  crosses  the  artery  from  without 
inward. 

Popliteal  Artery. — The  popliteal  artery  may  be  exposed  by  an  inci- 
sion along  a  line  drawn  from  a  point  just  inside  the  inner  hamstring 
above,  to  the  middle  of  the  lower  part  of  the  popliteal  space  below. 
The  skin,  superficial,  and  deep  fasciae  are  divided,  and  the  artery 
recognized  by  its  pulsations.  If  ligation  is  to  be  performed  in  the 
upper  part  of  the  space,  the  nerve  and  vein  will  be  found  to  the  outer 
side  of  the  artery,  and  should  be  drawn  outward.  If  the  lower  portion 
of  the  artery  is  to  be  ligated,  the  nerve  and  vein  will  be  found  to  the 
inner  side  of  the  artery,  and  should  be  retracted  inward.  In  this 
operation  the  external  saphenous  vein,  the  external  saphenous  nerve, 
the  plantaris  muscle,  and  the  sural  arteries  will  be  exposed  and  must 
be  avoided. 

Tibial  Arteries. — Anterior  Tibial  Artery. — The  anterior  tibial  artery 
may  be  exposed  in  any  part  of  its  course  by  an  incision  along  a  line 
drawn  from  a  point  midway  between  the  head  of  the  fibula  and  tuber- 
osity of  the  tibia  to  a  point  opposite  the  middle  of  the  front  of  the 
ankle.  The  incision  should  divide  the  skin,  superficial  fascia,  and  deep 
fascia.  The  line  of  division  between  the  tibialis  anticus  and  extensor 
proprius  pollicis  should  be  recognized  and  the  two  muscles  separated 
and  held  well  apart.  The  artery  will  be  found  at  the  bottom  of  the 
space  thus  formed,  lying  on  the  interosseous  membrane.  The  nerve 
lies  to  the  outer  side  of  the  artery.  In  the  upper  third  of  the  leg  the 
white  line  between  the  two  muscles  may  not  be  distinctly  seen.  In 
this  case  a  small  arterial  branch  may  sometimes  be  found  between  the 
two  muscles,  which  will  serve  as  a  guide.  The  intermuscular  septum 
lies  from  three-quarters  to  one  inch  from  the  crest  of  the  tibia. 

Posterior  Tibial  Artery. — The  posterior  tibial  artery  follows  a  line 
drawn  from  the  middle  of  the  lower  part  of  the  popliteal  space  to  a 
point  midway  between  the  tendo  Achillis  and  the  internal  malleolus. 
It  can  be  ligated  in  the  middle  of  the  leg  through  an  incision  a  finger's 
breadth  behind  the  inner  border  of  the  tibia.  This  should  expose  the 
long  saphenous  vein  and  nerve,  which  should  be  retracted.  The 
deep  fascia  is  next  split  and  the  edge  of  the  gastrocnemius  muscle  drawn 
aside.  The  tibial  attachment  of  the  soleus  is  recognized  and  divided 
at  a  point  half  an  inch  from  the  bone.  Beneath  this  the  vessels  and 
nerve  will  be  found  enclosed  in  a  process  of  the  deep  fascia  lying  on 
the  flexor  longus  digitorum  muscle.  The  nerve  lies  to  the  outer  side 
of  the  artery.  The  artery  is  exposed  at  the  ankle  by  a  semilunar 
incision  midway  between  the  tendo  Achillis  and  the  internal  malleolus, 


LIGATION  OF  ARTERIES  IN  CONTINUITY  277 

following  the  curve  of  the  latter.  The  artery  is  superficial  in  this 
position,  and  lies  just  beneath  the  deep  fascia.  The  nerve  is  external 
to  the  vessel.  Care  should  be  taken  to  avoid  opening  the  tendon 
sheaths. 

Peroneal  Artery. — The  peroneal  artery  may  be  exposed  by  an  inci- 
sion along  the  posterior  border  of  the  fibula,  dividing  the  skin  and 
fascia,  retracting  the  gastrocnemius  muscle,  and  incising  the  tibial 
attachment  of  the  soleus.  The  artery  lies  near  the  fibula  just  beneath 
the  deep  fascia. 

Dorsalis  Pedis  Artery. — The  dorsalis  pedis  artery  is  exposed  by  an 
incision  along  a  line  drawn  from  the  centre  of  the  front  of  the  ankle 
to  the  upper  part  of  the  first  interosseous  space.  The  vessel  lies 
between  the  tendons  of  the  extensor  proprius  pollicis  and  extensor 
longus  digitorum,  and  sometimes  is  covered  by  the  extensor  brevis 
digitorum. 


CHAPTER  XII. 
INJURIES  AND  DISEASES  OF  THE  LYMPHATIC  SYSTEM. 

INJURIES  OF  THE  LYMPH  CHANNELS. 

As  lymphatics  are  present  in  every  organ  and  tissue  of  the  body, 
every  wound,  cut,  or  severe  contusion  must  necessarily  be  associated 
with  injury  to  some  lymphatic  structure.  Unless  the  injury  involves 
the  largest  and  most  important  lymph  vessels,  however,  little  or  no 
disturbance  results,  and  no  special  treatment  is  required.  Injuries 
of  the  thoracic  duct  or  its  larger  mesenteric  branches  (lacteals)  may 
result  from  severe  traumata,  as  fractures  of  the  spine,  severe  crushes 
or  contusions 'of  the  thorax  and  abdomen.  These  injuries  are  not 
infrequently  fatal  from  failure  of  a  large  amount  of  the  nutritive 
products  of  digestion  to  reach  the  blood.  In  such  cases  the  chyle 
collects  in  the  abdomen,  pleura,  or  in  the  retroperitoneal  or  retropleural 
connective  tissue,  forming  chylous  ascites,  chylothorax,  or  large  retro- 
peritoneal collections  of  chylous  fluid,  which  may  become  infected, 
burrow,  and  point  in  the  groin  or  in  other  remote  situations.  Acci- 
dental injuries  of  the  thoracic  duct  at  or  near  its  terminal  delta  in 
the  neck  have  occasionally  occurred  as  the  result  of  surgical  procedures. 
The  pathognomonic  symptom  of  this  injury  is  the  sudden  flooding  of 
the  wound  with  a  milky  fluid,  which  issues  from  the  region  of  the 
junction  of  the  deep  jugular  and  subclavian  veins. 

Treatment. — The  treatment  of  chylous  ascites  or  chylothorax  has 
up  to  the  present  time  been  simply  the  employment  of  means  to  remove 
the  fluid  from  these  cavities  to  overcome  the  untoward  effects  of 
pressure.  In  several  instances  this  has  eventually  been  followed  by  a 
cure.  Laparotomy  with  a  view  to  locating  and  seeming  the  leaking 
vessel  would  be  indicated  in  a  case  of  chylous  ascites  which  persisted 
after  one  or  more  tappings.  In  accidental  wounds  of  the  cervical 
portion  of  the  thoracic  duct  the  leaking  point  should  accurately  be 
located,  clamped  and  ligated,  and  the  wound  closed  in  the  usual 
manner.  In  the  majority  of  instances  in  which  this  plan  has  been 
carried  out  no  untoward  results  have  followed,  probably  for  the  reason 
that  only  one  of  the  several  terminal  branches  of  the  duct  was  injured; 
or,  if  the  main  duct  was  ligated,  the  anastomosing  channels  which  are 
usually  present  between  the  duct  and  the  upper  two  or  three  intercostal 
veins  subsequently  dilated  and  carried  on  the  circulation. 

DISEASES  OF  LYMPH  CHANNELS  AND  LYMPH  NODES. 

General  Discussion. — It  is  important  in  dealing  with  the  affections 
of  the  lymphatic  system  to  have  a  clear  understanding  of  the  general 


DISEASES  OF  LYMPH  CHANNELS  AND  LYMPH  NODES     279 

structure,  its  relation  in  particular  to  the  intercellular  spaces,  the 
structure  of  the  nodes  and  their  relation  to  the  blood- vascular  system. 
In  the  accompanying  diagram  (Fig.  145)  the  general  arrangement 
of  the  system  is  portrayed  quite  without  any  reference  to  relative 


General  systemic  ci7'culatio7l 


Fig.  145. — Diagrammatic  drawing  to  illustrate  the  general  architecture  of  the 
lymphatic  vessels  and  nodes  with  reference  to  the  tissues  and  the  blood-vascular  system. 
a,  efferent  lymph  vessel  entering  the  vein;  b,  vein  from  lymph  node;  c,  efferent  lymph 
vessel;  d,  hilum;  e,  capsule;  /,  lymph  cord;  g,  lymph  sinuses  between  nodules  and 
cords;  h,  lymph  nodules;  i,  circular  sinus;  j,  afferent  lymph  vessel;  k,  lymphatic 
capillary  loop;  I,  epithelial  surface;  m,  indicating  a  second  lymph  node  interposed 
between  the  first  and  the  venous  system;  n,  lungs;  o,  heart;  p,  artery  to  the  lymph 
node;  q,  connective-tissue  framework;  r,  delicate  connective-tissue  strands  traversing 
the  sinuses  to  join  the  reticulum  of  the  nodule;  they  are  lined  by  the  endothelium  of 
the  sinus;  s,  tissue  cell;  t,  intercellular  spaces;  u,  transition  between  arterial  and 
venous  capillary. 


size  of  structures.  An  endothelial  lined,  lymphatic,  capillary  loop 
is  shown  in  the  intercellular  spaces  between  body  cells  not  far  from  an 
epithelial  surface.  In  this  same  area  an  arterial  capillary  is  in  trans- 
ition to  a  vein.  An  afferent  lymphatic  vessel  runs  from  the  loop  to 
the  periphery  of  a  lymphatic  node,  entering,  together  with  other 


280       INJURIES  AXD  DISEASES  OF   LYMPHATIC  SYSTEM 

similar  trunk-,  the  circular  sinus  that  extends  about  the  greater  part 
of  the  periphery  of  the  node.  From  this  circular  sinus  the  endothelial 
lined,  lymphatic  channels  run  about  the  periphery  of  the  nodules, 
then  about  the  lymph  cords  to  fuse  at  the  hilum  into  the  efferent  vessel 
which  is  then  portrayed  as  passing  through  a  second  similar  system 
of  nodes  and  thence  into  the  venous  system.  The  artery  and  veins 
to  the  lymph  node  are  shown  entering  and  leaving  the  hilum  and  cours- 
ing along  the  connective-tissue  trabecule  that  acts  as  a  supporting 
framework  for  the  node  structures.  Tiny  trabecuhe  lined  by  endothelial 
•  til-  transmit  bloodvessels  to  the  nodules  by  traversing  the  lymph 
sinuses.  The  connective-tissue  cells  in  these  trabecular  are  continuous 
with  the  delicate  reticulum  that  exi>t>  as  a  supporting  framework  for 
the  lymph  nodules.  The  lymphoid  cells  and  so-called  germ  centres  are 
portrayed  in  th<-  nodule.  The  bloodves-els  are  shown,  for  simplicity's 
sake,  entering  only  one  nodule  and  one  lymph  cord. 

Let  us  imagine  the  presence  of  an  irritating  substance  'for  instance, 
a  pathogenic  micro-organism)  in  the  intercellular  spaces  of  the  area  /. 
Let  us  follow  the  possible  effects  with  special  reference  to  the  lymphatic 
system.  The  chemistry  and  physical  properties  of  the  intercellular 
fluids  will  be  altered,  and  the  nutrition  of  the  neighboring  cells  inter- 
fered with.  Bearing  in  mind  the  vast  and  complicated  number  of 
local  changes  that  may  occur,  with  an  inflammatory  process,  such  as 
those  associated  with  exudation  of  cells  and  serum,  formation  of 
fibrin,  the  appearance  of  ferments,  such  as  leukoprotease,  etc.,  as 
demonstrated  by  Opic — and  other  changes,  such  a-  those  that  have 
been  elucidated  by  the  work  of  Yaughan  and  many  others — irritating 
substances  may  be  distributed  to  other  parts  of  the  body,  either  by 
extension  along  the  intercellular  spaces  locally,  by  the  blood  capil- 
laries, or  by  the  lymphatic  capillaries.  As  irritating  substances  pa  — 
along  the  main  lymphatic  afferent  vessels  the  reaction  produced  in  the 
tissues  just  outside  of  the  vessel  wall  may  cause  a  superficial  appearance 
of  inflammation,  with  the  characteristic  red  streaks  well  known  in 
cases  of  acute  lymphangitis.  It  has  been  demonstrated,  with  consider- 
able substantiation  of  the  theory,  that  at  the  outset  of  an  acute  inflam- 
matory process  the  patent  viable  lymph  sinuses  in  the  nodes  act  as 
channels  through  which  irritating  substances  may  reach  the  blood 
stream  practically  unchanged  and  without  restraint.  Observers  have 
spoken  of  this  process  as  the  "initial  rush"  through  the  lymphatics. 
Clinical  observations  lend  support  to  this  theory.  Very  shortly, 
however,  after  the  arrival  of  irritating  substances  in  the  lymph  sinuses 
a  very  extensive  increase  in  the  number  of  lymphoid  cells  and  cells 
that  have  exuded  from  the  bloodvessels  appear  in  the  nodules.  The 
sinuses  are  filled  with  varying  types  of  phagocytes.  If  the  substances 
are  very  irritating  and  their  supply  small  we  speak  of  this  condition  as 
an  acute  hyperplasia.  If  the  process  is  prolonged  and  the  substances 
are  less  irritating  we  speak  of  a  chronic  hyperplasia.  It  is  well  to 
consider  that  in  the  intercellular  spaces  between  the  lymphoid  cells 


DISEASES  OF  LYMPH  CHANNELS  AND  LYMPH  NODES     281 

of  the  nodules  and  cords  there  is,  as  it  were,  a  common  meeting  ground 
for  the  fluids  and  cells  derived  from  the  original  sources  of  irritation 
through  the  lymph  channels,  and  the  fluid  or  cells  derived  from  the 
systemic  blood-vascular  system.  Besides  these  two  factors  is  the 
enormous  hyperplasia  of  lymphoid  cells  that  occurs  in  the  same  area. 
The  lymph  that  has  passed  through  the  node  or  a  series  of  nodes  by 
their  efferent  vessels  into  the  veins  has  accordingly  had  ample  oppor- 
tunity for  modification.  Going  a  step  further,  let  us  imagine  venous 
blood  that  is  receiving  continuous  minute  doses  of  these  modified 
irritating  substances.  It  passes  to  the  lungs,  receives  oxygen  and  is 
then  distributed  to  all  parts  of  the  body,  there  to  be  modified  by  the 
various  organs  and  tissues,  finally  to  return  tremendously  diluted 
through  the  artery  of  the  lymph  node  and  there  distribute  its  effects, 
modified  by  its  journey,  in  the  intercellular  spaces  of  the  nodule. 
It  is  strongly  suggestive  that  in  these  intercellular  spaces  of  the 
lymph  nodules  one  of  the  most  important  laboratories  in  the  body 
may  exist  for  the  elaboration  of  immune  substances. 

Lymphangitis;  Lymphadenitis. — A  certain  amount  of  lymphangitis 
is  present  in  the  neighborhood  of  all  infected  wounds,  and  cellulitis, 
and  has  been  described  in  Chapter  X.  As  the  function  of  the  lymph 
nodes  is  to  arrest  or  modify  infectious  matter  carried  upward  through 
the  lymph  channels  toward  the  blood,  and  to  hold  this  poisonous 
material  until  the  local  process  has  subsided  or  until  the  blood  is 
capable  of  neutralizing  or  eliminating  it,  the  nodes  become  enlarged, 
tender,  and  often  acutely  inflamed  during  the  progress  of  a  septic 
inflammation  in  the  region  drained  by  their  afferent  channels.  Certain 
forms  of  infection  have  apparently  little  tendency  to  cause  inflammation 
in  the  lymphatic  vessels  or  nodes;  while  others,  as  those  due  to  the 
streptococcus  group  of  micro-organisms,  attack  at  once  the  lymphatic 
structures,  spread  rapidly  along  the  channels,  and  cause  early  enlarge- 
ment of  the  nodes. 

Symptoms. — The  symptoms  of  lymphangitis  are  pain,  tenderness, 
and  the  presence  of  lines  or  patches  of  redness  and  edema  extending 
upward  along  the  chief  lymph  vessels  toward  the  trunk.  The  lymph 
nodes  along  the  course  of  these  vessels  enlarge,  become  tender  to 
the  touch,  and  may  be  surrounded  by  an  area  of  redness  and  edema  of 
the  skin  and  cellular  tissue.  With  these  local  symptoms  there  is 
generally  considerable  systemic  reaction,  evidenced  by  chills,  fever, 
headache,  general  malaise,  and  more  or  less  prostration.  In  the 
milder  cases  these  symptoms  rapidly  subside  as  soon  as  the  original 
source  of  the  infection  is  removed  and  secondarily  infected  areas  are 
opened  and  drained.  In  the  severer  cases,  when  the  original  infection 
is  a  virulent  one,  as  an  autopsy  or  other  poisoned  wound  of  the  finger, 
the  general  symptoms  may  precede  by  several  hours  the  local  mani- 
festations, due  to  the  so-called  initial  rush,  and  a  high  grade  of  septic 
intoxication  or  even  true  septicemia  may  develop.  Clinically,  injuries, 
such   as   contusions   of   tissues  through  which  chronically  inflamed 


282       INJURIES  AND  DISEASES  OF  LYMPHATIC  SYSTEM 

lymphatic  trunks  have  their  course,  may  result  in  infection  due  to 
the  extravasation  of  bacteria,  or  cells  containing  bacteria  from  the 
ruptured  lymph  vessels  transmitting  them.  Extensive  and  often  mul- 
tiple areas  of  suppuration  follow  lymphangitis,  due  to  perivascular 
cellulitis  or  glandular  abscess. 

Treatment. — The  treatment  of  lymphangitis  in  the  early  stages  should 
consist  in  removal,  if  possible,  of  the  original  focus  of  infection,  and 
the  application  of  a  dressing  of  20  per  cent,  ichthyol  ointment,  of  mer- 
curic chloride  (1  to  5000)  or  of  aluminium  acetate  to  the  inflamed  areas. 
This  is  often  promptly  successful.  The  primary  focus  of  infection 
should  be  treated  and  incised  if  necessary.  Should  the  lymphangitis 
become  a  diffuse  cellulitis  or  abscess,  it  should  be  treated  as  such. 
Excision  of  lymph  nodes  in  acute  lymphangitis  is  to  be  condemned; 
incision  is  indicated  only  with  abscess  formation  or  very  severe  and 
rapidly  spreading  infections.  Acute  lymphadenitis  is  of  necessity 
associated  sooner  or  later  with  acute  lymphangitis.  The  nodes  become 
enlarged  and  tender.  They  usually  subside  with  proper  attention  to 
the  source  of  infection.  Small  abscesses  may  form,  however,  coalesce 
and  with  extension  to  the  surrounding  tissues  form  one  large  abscess. 
This  often  occurs  in  the  neck,  the  axilla,  and  the  groin.  They  can 
generally  be  opened  through  rather  small  incisions,  inasmuch  as  the 
process  is  well  walled  off,  and  as  soon  as  the  pus  effects  an  exit,  repair  is 
rapid. 

Obstruction  of  the  Lymph  Channels. — Obstruction  of  the  lymph 
channels  may  be  due  to  inflammatory  processes,  to  the  pressure  of 
new  growths,  to  the  presence  in  the  lymph  channels  of  a  parasite, 
Filaria  sanguinis  hominis,  to  the  excision  of  all  the  nodes  and  portions 
of  their  afferent  channels,  as  in  the  close  stripping  of  the  axillary  vein 
in  operations  for  mastectomy,  or  to  congenital  conditions  the  nature 
of  which  is  not  understood.  Obstruction  of  the  lymph  channels 
may  result  in  lymphedema,  or  swelling  of  all  the  lymph  channels  and 
spaces  over  a  large  area,  or  to  localized  swellings  or  vascular  dilatations. 

Lymphedema,  or  Elephantiasis. — Lymphedema,  or  elephantiasis,  is 
a  condition  of  hypertrophy  of  the  skin  and  cellular  tissue  resulting  in 
great  deformities.  It  is  of  frequent  occurrence  in  tropical  countries, 
where  it  is  generally  due  to  Filaria  sanguinis  hominis.  It  affects 
chiefly  the  lower  extremities  the  external  genitals  of  both  sexes, 
occasionally  the  arms  and  other  parts  of  the  body.  In  many  instances 
elephantiasis  of  filarial  origin  is  observed  without  the  presence 
of  embryos  in  the  blood.  In  these  cases  it  is  probable  that  the  parent 
worms  occupy  the  main  lymphatic  channels  of  the  affected  limb,  and 
by  their  presence  cause  an  obliterative  inflammation  which  prevents 
their  embryos  gaining  entrance  to  the  general  lymph  or  blood  streams. 

The  chief  pathologic  factors  in  elephantiasis  are,  first,  an  obstructed 
lymph  current,  and  second,  an  enormous  overgrowth  of  connective 
tissue.  The  skin  becomes  exceedingly  thick,  coarse,  pigmented,  and 
thrown  into  folds  and  creases.     There  is  often  a  foul  discharge  with  a 


DISEASES  OF  LYMPH  CHANNELS  AND  LYMPH  NODES     283 

tendency  toward  the  formation  of  ulcers.  The  same  condition  is  not 
infrequently  seen  in  the  foot  and  lower  leg  of  an  individual  suffering 
from  chronic  ulcer  when  the  ulcer  is  extensive  and  nearly  encircles 
the  limb  (Fig.  146).  Gerrish  has  reported  an  example  of  elephantiasis 
of  the  scrotum  due  to  the  pressure  of  a  double  truss  worn  for  the  relief 
of  hernia. 

Symptoms. — The  symptoms  of  elephantiasis  are  at  first  only  an 
edema  and  moderate  enlargement  of  the  limb.  Later  there  occur 
attacks  of  dermatitis,  or  erysipelas  with  fever,  lumbar  pain,  and 
general  malaise.  This  causes  a  thickening  of  the  skin  which,  as 
the  subcutaneous  areolar  tissue  hypertrophies,  forms  creases  and 
folds  in  which  dirt,  sebaceous  material,  and  moisture  collect,  giving 


Fig.  146. — Old  ulcer  of  the  leg  with  lymphedema. 

rise  to  a  foul-smelling  and  irritating  discharge.  In  many  instances 
the  increase  in  size  of  the  affected  part  is  enormous,  and  constitutes 
a  disfiguring  and  burdensome  deformity.  These  extreme  examples 
of  the  disease  are  rarely  seen  in  temperate  climates,  but  in  some 
tropical  countries  where  filariasis  is  common  a  fair  proportion  of  the 
inhabitants  suffer  from  the  malady.  In  many  cases  the  diagnosis 
can  be  made  by  finding  the  parasites  in  the  blood  of  a  patient  at  night, 
or  sometimes  in  the  daytime  after  rest  in  bed. 

Treatment. — The  treatment  of  this  condition  is  unsatisfactory. 
In  some  instances,  in  the  early  stage  of  the  affection,  elevation  of  the 
limb,  massage,  and  bandaging  may  be  of  temporary  benefit.  As  a 
rule,  however,  surgical  advice  is  not  sought  until  the  disease  is  well 


284      INJURIES  AXD  DISEASES  OF  LYMPHATIC  SYSTEM 

advanced.  Warm  baths  and  care  in  the  cleansing  of  the  cutaneous 
creases  and  pockets  is  essential  for  the  prevention  of  infection.  Oper- 
ative treatment  is  to  be  recommended  when  the  disease  becomes 
burdensome.  The  ideal  procedure  is  to  remove  the  primary  site  of 
infection  if  it  can  be  located  and  excised.  This  is  rarely  possible. 
In  a  number  of  cases  of  elephantiasis  of  the  lower  limb,  much  can  be 
accomplished  by  removal  of  large  wedge-shaped  areas  with  subsequent 
closure  of  the  wounds  and  aseptic  healing.  In  this  manner  limbs  can 
sometimes  be  rendered  useful,  which  before  operation  were  a  serious 
impediment  to  locomotion.  The  employment  of  multiple  setons 
for  lymphedema  has  recently  been  suggested,  and  considerable  improve- 
ment has  followed  their  use,  especially  in  the  swollen  arms  which  not 
infrequently  follow  a  complete  breast  amputation.  In  some  instances 
amputation  is  to  be  recommended.  If  the  disease  affects  the  scrotum 
or  labia  majora,  complete  or  partial  ablation  is  to  be  advised. 

In  all  operative  procedures  upon  these  cases  great  care  should  be 
exercised  in  regard  to  hemostasis,  as  the  vessels,  particularly  the  veins, 
are  enormously  enlarged  and  hemorrhage  is  often  alarming. 

Localized  Lymphatic  Dilatations;  Lymphangiomata. — In  this  con- 
dition the  dilated  lymph  vessels  resemble  the  angiomata  of  blood- 
vessels, except  that  the  mass  is  colorless.  The  disease  may  affect  the 
lymphatic  capillaries  or  the  larger  vessels,  giving  rise  in  the  former 
instance  to  small  areas  of  colorless  dilated  lymphatics,  the  so-called 
lymphatic  nevi;  in  the  latter  to  cavernou>  lymphangiomata,  irregular 
compressible  tumors  made  up  of  masses  of  dilated  lymph  vessels. 
The  etiology  of  these  conditions  is  obscure;  a  certain  number  of  the 
eases  of  lymphangiomata  which  occur  in  the  scrotum,  groin,  and 
in  the  retroperitoneal  lumbar  region  are  undoubtedly  due  to  Filaria 
sanguinis  hominis.  These  are  often  associated  with  lumbar  pain, 
severe  intermittent  fever,  chyluria,  hematuria,  and  occasionally 
chylous  hydrocele.  Macroglossia,  macrocheilia,  and  macrodactylia,  or 
enlargements  of  the  tongue,  lips  or  fingers,  are  occasionally  encountered 
as  congenital  affections  due  to  lymphatic  obstruction. 

Treatment. — The  treatment  of  all  these  conditions  is  rather  unsatis- 
factory. Electrolysis  is  to  be  advised  in  the  smaller  lymphangiomata. 
In  the  larger  tumors  excision  is  to  be  attempted.  Even  the  largest 
sometimes  may  be  removed  and  the  deformities  thus  created  repaired 
by  plastic  procedures.  As  in  the  case  of  hemangiomata,  small 
lymphangiomata  can  be  successfully  treated  by  liquid  air. 

Tuberculosis  of  the  Lymph  Nodes. — Tuberculosis  of  the  lymph 
nodes  is  of  frequent  occurrence.  As  in  cases  of  septic  infection,  the 
nodes  act  as  barriers  and  temporarily  arrest  the  transit  of  infectious 
material  toward  the  general  circulation.  Where  the  primary  focus 
of  absorption  is  small  and  the  resistance  of  the  individual  great, 
the  nodes  may  enlarge,  remain  stationary  for  a  period,  until  the  original 
source  of  infection  is  removed  or  disappears,  and  then  gradually 
disappear,  the  infectious  material  which  they  contain  being  destroyed 


DISEASES  OF  LYMPH  '  H  ANN  ELS  AND  LYMPH  NODES     285 

by  the  bactericidal  elements  of  the  economy.  It  has  beeD  claimed 
by  many  observers  that  most  cases  of  cervical  lymph  node  tuberculosis 
are  due  to  an  infection  by  the  bovine  type  of  tubercle  bacilli.  When 
the  condition-  arc  less  favorable  to  spontaneous  resolution,  the  disease 
gradually  results  in  destruction  of  the  node-,  the  development  of 
periadenitis,  with  involvement  of  the  surrounding  areolar  tissue, 
fascia,  and  muscle.  In  the  early  stages  of  the  affection  there  is  appar- 
ently a  simple  hypertrophy  of  the  nodes,  which  on  cut  section  present 
only  a  pinkish  or  gray  homogeneous  appearance.  Later,  cheesy  foci 
develop  and  the  entire  node  may  caseate  and  liquefy,  or,  as  a  result 
of  secondary  infection,  an  abscess  may  develop  and  discharge  spon- 
taneously, leaving  a  chronic  fistulous  tract  leading  to  a  necrotic  and 
partly  disorganized  lymph  node.  The  disease  occur-  most  frequently 
in  the  cervical  region,  the  source  of  infection  being  located  in  the  oral, 
pharyngeal,  or  nasal  cavity.  It  also  occurs  in  the  bronchial  or  medias- 
tinal nodes  from  some  tuberculous  focus  in  the  lung;  in  the  mesenteric 
lymphatics,  from  some  focus  in  the  intestine;  in  the  nodes  of  the  groin, 
axilla,  or  lumbar  region,  from  foci  in  the  tissues  drained  by  their 
afferent  vessels. 

Tuberculosis  of  the  Cervical  Lymph  Nodes. — This  condition  is  of  com- 
mon occurrence,  and  gives  rise  to  deformity,  for  the  relief  of  which  the 
surgeon  is  frequently  consulted.  In  the  majority  of  instances  the 
disease  arises  from  some  focus  in  the  pharyngeal  or  faucial  tonsil. 
It  is  impossible  to  state  with  certainty  the  source  of  infection  of  all 
cervical  tuberculous  nodes.  Likely  sources  of  infection  may  be  a 
carious  tooth,  a  suppurating  middle  ear,  or  some  other  open  lesion 
of  the  nose,  mouth,  or  scalp.  It  has  also  been  demonstrated  experi- 
mentally that  a  tuberculous  infection  of  a  cervical  lymph  node  may 
follow  the  application  of  tubercle  bacilli  to  the  nasal  mucous  membrane 
without  giving  rise  to  a  local  lesion  i  Cornet). 

A  glance  at  Plate  XI  will  show  the  general  arrangement  of  the 
lymph  nodes  of  the  neck.  Of  the  five  superficial  groups,  the  occipital 
group  receives  lymph  from  the  back  of  the  neck  and  posterior  portion 
of  the  scalp;  the  mastoid  group  and  those  lying  on  the  external  surface 
of  the  upper  third  of  the  sternomastoid  muscle,  from  the  parietal 
region  of  the  scalp  and  posterior  part  of  the  meatus  and  external  ear; 
the  parotid  group,  divided  into  the  deep  group  that  is  situated  in  and 
posterior  to  that  portion  of  the  gland  projecting  deep  into  the  neck 
beneath  the  pterygoid  muscles,  and  the  superficial  group  scattered 
extensively  throughout  that  portion  of  the  gland  in  front  of  the  ear, 
and  beneath  the  deep  fascia,  the  former  from  the  posterior  naso- 
pharyngeal region,  the  latter,  from  the  anterior  part  of  the  auricle, 
the  temporal  region,  and  upper  part  of  the  face;  the  submaxillary, 
from  the  lateral  aspect  of  the  lips,  gums,  teeth,  anterior  half  of  the 
tongue,  and  floor  of  the  mouth;  the  submental,  from  the  same  regions, 
but  nearer  the  median  line.  It  is  noteworthy  that  the  submaxillary 
salivary  gland  does  not  have  lymph  nodes  developed  in  its  substance 


286       INJURIES  AND  DISEASES  OF  LYMPHATIC  SYSTEM 


normally  as  does  the  parotid.  The  deep  cervical  group  of  lymph 
nodes  which  lies  beneath  the  sternomastoid  muscle  along  the  internal 
jugular  vein  receives  the  lymph  from  all  of  the  superficial  groups, 
and  extends  downward  to  the  junction  of  the  jugular  and  subclavian 
veins.  It  also  receives  direct  channels  from  the  tongue,  palate, 
pharynx,  nasal  fossae,  and  larynx.  A  knowledge  of  these  facts  will 
often  enable  one  to  find  the  original  source  of  infection  when  dealing 
with  malignant,  septic,  or  tuberculous  involvement  of  the  cervical 
nodes. 

Symptoms.— The  symptoms  of  this  condition  are,  at  first,  a  painless 
enlargement  of  one  or  more  lymph  nodes,  which  present  no  evidences  of 

acute  inflammation.  They  feel  firm, 
are  discrete,  and  freely  movable. 
Later,  they  become  larger  and  adhere 
to  each  other  and  to  the  surround- 
ing structures,  giving  rise  to  irreg- 
ularly shaped  tumors  which  are 
more  or  less  fixed.  Fluctuation  may 
develop  or,  if  secondary  infection 
occurs,  the  surrounding  skin  be- 
comes red  and  infiltrated.  There  is 
at  first  no  apparent  effect  on  the  gen- 
eral health,  in  fact  it  is  remarkable 
how  frequently  tuberculous  cervical 
lymph  nodes  occur  in  individuals 
who  are  otherwise  in  the  most  per- 
fect health:  but  later  there  may  be 
anemia,  and  fever;  night-sweats, 
and  wasting  may  occur  in  the  later 
stages.  In  other  cases  the  disease 
seems  to  follow  an  acute  septic 
involvement  of  the  nodes,  as  after 
scarlet  fever,  acute  tonsillitis,  or 
diphtheria.  A  diminished  resist- 
ance to  tuberculosis  occurs  with 
measles,  influenza  and  whooping- 
cough.  In  these  instances  it  is 
probable  that  the  nodes  were  already  infected  by  the  tubercle  bacilli, 
and  that  the  process  was  stimulated  by  the  septic  invasion. 

As  a  rule,  the  first  nodes  to  become  enlarged  are  those  in  the  sub- 
maxillary region  or  those  situated  about  the  upper  third  of  the  internal 
jugular  vein.  As  the  disease  progresses  the  nodes  lower  down  in  the 
chain  become  involved,  also  those  situated  behind  the  sternomastoid 
muscle,  and  in  the  posterior  cervical  triangle.  In  advanced  cases  the 
entire  lateral  aspect  of  the  neck  may  present  an  irregular  nodular 
enlargement  (Figs.  147,  148,  and  149).  When  suppuration  occurs, 
which  is  generally  the  result  of  a  mixed  infection,  the  skin  becomes  red 


Fig.  147. 


-Tuberculous  lymph   nodes 
of  neck. 


DISEASES  OF  LYMPH  CHANNELS  AND  LYMPH  NODES      287 

and  edematous,  fluctuation  develops,  and  spontaneous  rupture  may 
occur.     The  resulting  sinus  may  remain  open  for  an  indefinite  period, 


Fig.  148. — Solitary  lymph  node  of  neck. 

and  its  external  opening  is  often  surrounded  by  a  pouting  purple 
area  of  infiltration  (scrofuloderma). 

Prognosis. — In  a  number  of  cases  spontaneous  recovery  follows  a 
change  to  more  favorable  hygienic  surroundings.  Arrest  of  the 
process,  but  with  little  tendency  to  resolution,  is  more  frequently 


Fig.  149. — Multiple  tuberculous  lymph  nodes  of  neck  and  face. 

observed.     In  a  number  of  late  reports,  made  by  careful  observers 
in  cases  treated  medically,  it  has  been  shown  that  from  20  or_40  per 


288       INJURIES  AND  DISEASES  OF  LYMPHATIC  SYSTEM 

cent,  eventually  develop  tuberculosis  of  the  lungs  or  other  important 
organs.  The  results  following  incomplete  surgical  operations  show 
little  to  encourage  the  timid  operator,  but  in  those  clinics  where 
thorough  and  painstaking  surgical  procedures  are  carried  out,  the 
percentage  of  recoveries  is  from  75  to  90. 

Treatment. — In  the  treatment  of  this  disease,  as  in  other  tuberculous 
conditions,  certain  hygienic  measures  should  always  be  adopted  if 
the  best  results  are  to  be  obtained.  Life  in  the  open  air — particularly 
at  the  seashore  or  mountains — sleeping  out  of  doors,  or  in  rooms  with 
wide-open  windows,  and  abundance  of  good,  nourishing  food,  carefully 
supervised  exercise  with  prolonged  hours  of  rest  and  sleep,  avoidance 
of  irritation  to  the  probable  source  of  infection,  and  sometimes  elastic 
rubber-tube  constriction  about  the  neck,  as  recommended  by  Bier 
for  passive  hyperemia,  will  not  infrequently  result  in  a  spontaneous 
disappearance  of  the  enlarged  nodes  without  other  treatment. 

Surgical  Treatment. — If  after  a  period  of  observation  under  careful 
conservative  treatment  there  is  no  evidence  of  improvement,  the 
general  rule  to  excise  entirely,  where  possible,  a  tuberculosis  focus 
holds  good.  But  the  lymph  node  may  not  be  the  only  focus  or  even 
the  main  focus.  The  removal  of  a  chronically  inflamed  tonsil  or  mass 
of  adenoid  tissue  from  the  phalanx,  may  remove  the  source  of  infec- 
tion, or  perhaps  a  persistent  source  of  irritation  to  the  nodes. 

If  this  has  been  done  and  the  enlargement  of  the  nodes  persists, 
radical  enucleation  should  be  advised.  When  the  infection  has  not  yet 
progressed  to  the  tissues  outside  the  nodes,  this  is  comparatively  simple, 

Other  conditions,  however,  may  obtain. 

1.  There  may  be  extensive  adhesions  binding  groups  of  nodes 
together  and  to  surrounding  structures  in  atypical  masses.  In  these 
cases  a  bloc  dissection  should  be  performed.  It  may  be  long  and 
difficult  and  involve  division  of  sternomastoid  muscle  below  the  spinal 
accessory,  and  occasionally  resection  of  the  jugular  veins. 

2.  Shutting  off  of  blood  supply,  areas  of  coagulative  necrosis  either 
as  single,  large,  or  multiple,  smaller,  cold  abscesses  may  develop, 
confined  either  to  single  nodes  or  all  the  nodes  of  a  single  group, 
or  to  many  nodes  in  many  groups.  As  complete  an  excision  as 
possible  and  care  to  obliterate  all  dead  spaces  is  here  indicated. 

3.  Extension  of  the  tuberculous  infection  to  the  tissues  outside 
the  nodes  causing  a  diffuse  tuberculous  cellulitus  with  or  without  large 
areas  of  coagulative  necrosis.  Here,  again,  excision  should  be  com- 
plete, and  where  impossible,  by  as  thorough  removal  as  possible  with 
a  sharp  curet.     In  this  type  there  frequently  occur: 

4.  Tuberculous  sinuses.  These  should  be  conservatively  treated 
by  measures  calculated  to  keep  the  sinuses  scrupulously  clean.  Elimi- 
nation of  secondary  pyogenic  infection,  stimulation  and  increasing 
the  blood  supply  to  the  tract.  This  is  often  favored  by  the  use  of  the 
Bier  cups. 

Frequent  dressings,  occasional  instillations  of  pure  carbolic  acid, 


DISEASES  OF  LYMPH  CHANNELS  AND  LYMPH  NODES     289 

cupping,  sometimes  the  use  of  tincture  of  iodine,  and,  if  the  eavity 
is  not  too  large,  injections  of  Mosetig-Moorhof  s  iodoform  emulsion 
(care  being  taken  not  to  inject  too  much)  are  all  useful.  The  dressing 
and  care  of  a  tuberculous  sinus  is  one  of  the  most  interesting  of  out- 
patient problems.  The  general  hygienic  measures  are  of  the  greatest 
importance  in  these  cases. 

5.  Pyogenic  infection  of  already  existing  tuberculous  lymph  nodes. 
These  cases,  frequent  in  children,  generally  show  a  fluctuating,  red- 
dened, tender  abscess  pointing  through  the  skin.  A  very  minute 
incision  suffices  for  drainage.     Later  the  nodes  may  be  removed. 


Fig.  150. — -Two  transverse  incisions  for  removing  moderately  enlarged  nodes.     (Dowd.) 

As  regards  the  operation  itself  the  incisions  must  be  adapted  to  the 
location  of  the  diseased  nodes.  For  cosmetic  results  and  also  because 
they  tend  to  fall  together  and  obliterate  the  dead  spaces  if  made  in 
the  natural  lines  of  the  skin  (Fig.  150),  the  accompanying  illustrations 
show  the  favorite  methods.  A  combination  of  the  upper  submaxillary 
incision  with  a  posterior  vertical  incision  has  been  frequently  employed 
by  the  writer  in  cases  of  extensive  disease  (Fig.  151).  The  supra- 
maxillary  branch  of  the  lower  division  of  the  seventh  in  its  course 
below  the  ramus,  the  spinal  accessory  nerve,  the  muscular  branches 
from  the  cervical  plexus,  and  the  thoracic  duct  are  the  main  structures 
that  have  been  cut  with  disastrous  results  and  must  be  safeguarded. 

There  is,  in  the  nature  of  the  operation,  an  extensive  cutting  of 
19 


290       INJURIES  AND  DISEASES  OF  LYMPHATIC  SYSTEM 

lymph  vessels.  Accumulations  of  lymph  may  occur  for  two  to  three 
days  after  operation.  Some  drainage,  but  only  the  minimum  amount 
should  be  instituted.  Very  small  rubber  tubes,  gutta-percha  tissue, 
twisted  silkworm-gut  strands  are  the  favorite  drains  used. 

A  snug,  soft  dressing  reinforced  by  a  starch  or  an  Ideal  bandage, 
though  somewhat  uncomfortable,  is  a  most  efficient  method  of 
obliteration  of  dead  spaces  and  giving  rest  to  the  part. 

When  possible,  the  individual  nodes  should  be  enucleated,  largely 
by  blunt  dissection.  When  extensive  fascial  or  muscular  tuberculosis 
exists,  a  most  painstaking  and  careful  dissection  will  be  necessary. 


Fig.  151. — The  hockey-stick  incision.     (Dowd.) 

Syphilis  of  the  Lymph  Nodes. — Enlargement  of  the  lymph  nodes 
occurs  during  the  early  stages  of  syphilis,  and  requires  no  treatment 
other  than  the- internal  and  external  use  of  mercury  with  injections  of 
salvarsan.  Gummatous  infiltration  of  the  lymphatics,  however, 
may  occur  late  in  the  disease,  and  the  enlargements  thus  produced 
may  break  down  and  result  in  sinuses  resembling  those  caused  by 
tuberculosis,  or  in  extensive  syphilitic  ulceration  of  the  surrounding 
skin.  As  a  rule,  all  of  these  conditions  can  be  cured  by  judicious 
treatment  with  mercury,  potassium  iodide,  the  local  use  of  blue 
ointment  and  injections  of  salvarsan.  Occasionally  it  will  be  advisable 
to  remove  such  gummatous  tumors  which  seem  about  to  break  down. 


DISEASES  OF  LYMPH  CHANNELS  AND  LYMPH  NODES     291 

Chronic  Lymphadenitis,  Simple  Hyperplasia  of  the  Lymph  Nodes,  or 
Benign  Lymphadenoma. — These  are  terms  which  have  been  applied 
to  chronic  non-snppnrative  enlargements,  which  are  apparently  not 
due  to  tuberculosis,  syphilis,  or  Hodgkin's  disease.  Such  nodes  are 
occasionally  associated  with  chronic  otitis  media,  facial  eczema, 
pediculosis  of  the  scalp,  and  other  sources  of  irritation  or  subacute 
inflammations  in  the  regions  drained  by  their  afferent  vessels.  If 
such  enlargements  do  not  subside  after  removal  of  the  peripheral 
irritation,  they  are  in  all  probability  tuberculous  in  character  or  due 
to  Hodgkin's  disease. 


Fig.  152. — Early  tubercular  infection  of  the  deep  cervical  chain:  A,  most  prominent 
caseous  node;  B,B,  caseous  nodes  under  sternomastoid  muscle;  C,C,  sternomastoid 
muscle;  D,D,D,D,  spinal  accessory  nerve;  E,  trapezius  muscle;  F,  levator  anguli 
scapula?  muscle;  G,G,G,  branches  of  cervical  plexus;  H,  scalenus  posticus  muscle;  /, 
external  jugular  vein;  K,  course  of  posterior  branch  of  spinal  accessory  nerve  cut  from 
sternomastoid  muscle;  L,  omohyoid  muscle;  M,  internal  jugular  vein;  X,  facial  vein; 
0,  posterior  facial  vein  (anterior  division  of  temporomaxillary) ;  P,  parotid  gland. 
(Dowd.) 


Malignant  Lymphadenoma,  or  Hodgkin's  Disease. — This  disease  is 
characterized  by  a  gradual  enlargement  of  the  lymph  nodes  of  the 
body  eventually  resulting  in  grave  anemia,  progressive  asthenia, 
wasting  cachexia,  and  death.  The  disease  begins  by  a  painless  enlarge- 
ment of  several  lymph  nodes,  generally  on  one  side  of  the  neck.  The 
glands  are  discrete,  freely  movable  at  first,  and  show  no  tendency 
to  suppurate  or  undergo  caseous  degeneration.  The  disease  gradually 
extends  and  involves  the  glands  on  the  opposite  side,  those  in  the  axillae, 
groins,  abdomen,  and  mediastinum.  Later  they  become  fused,  often 
forming  enormous  irregular  masses  which  cause  great  disfigurement 
(Fig.  153).     The  spleen  and  other  lymphoid  tissues  enlarge,  anemia 


292       INJURIES  AND  DISEASES  OF  LYMPHATIC  SYSTEM 

and  a  progressive  emaciation  occur,  and  the  patients  finally  die  of 
exhaustion.  During  the  past  five  or  six  years  considerable  discussion 
has  taken  place  regarding  the  nature  of  this  disease.  It  is  probably 
due  to  a  cause  of  infectious  nature,  the  identification  of  which  has  never 
been  made. 

On  microscopical  section  there  is  a  diffuse  hyperplasia  of  the  elements 
of  the  node,  with  a  disappearance  of  the  nodules,  the  appearance 
of  large  cells  containing  three  or  four  or  more  nuclei,  many  eosinophiles 
and  often  extensive  areas  of  young  connective-tissue  cells. 


Fig.  153. — Hodgkin's  disease. 


The  disease  is  one  that  belongs  rather  to  the  domain  of  internal 
medicine  than  to  surgery,  as  operative  treatment  in  the  early  stages 
has  accomplished  little  except  the  removal  of  deformity  and  the  relief 
of  pressure-symptoms.  It  is  of  surgical  interest  mainly  from  the  point 
of  view  of  diagnosis,  as  it  at  times  closely  simulates  tuberculous 
adenitis,  and  at  other  times  is  occasionally  mistaken  for  true  lympho- 
sarcoma. 

The  term  chronic  relapsing  fever  has  been  used  by  Ebstein  and 
others  to  describe  a  peculiar  symptom-complex  which  is  occasionally 
observed  in  these  cases.  The  symptoms  of  this  condition  are  the 
occurrence  of  attacks  of  high  fever  and  prostration  associated  with  an 


DISEASES  OF  LYMPH  CHANNELS  AND  LYMPH  NODES     293 

enlarged  and  tender  spleen  and  with  moderate  swelling  and  sensitive- 
ness of  one  or  more  lymph  nodes  of  the  neck  or  in  other  external 
regions  of  the  body.  The  attacks  occur  at  intervals  of  a  few  weeks 
or  months,  gradually  becoming  more  severe,  and  finally  resulting  in 
profound  asthenia,  wasting,  and  death.  There  are  no  characteristic 
blood  changes  in  the  early  attacks,  and  the  condition  often  resembles 
a  profound  septic  intoxication. 

Treatment. — The  treatment  of  Hodgkin's  disease  is  unsatisfactory. 
The  .r-rays  will  often  cause  the  enlarged  nodes  to  diminish  in  size 
for  a  longer  or  shorter  period. 

Arsenic  in  the  early  stages  will  often  appear  to  arrest  the  process 
temporarily,  but  progress  is  inevitable  and  death  always  results. 
Removal  of  individual  nodes  is  of  no  avail,  and  is  to  be  recommended 
only  for  purposes  of  diagnosis,  to  relieve  pressure-symptoms  or  to 
overcome  deformity. 

Lymphatic  Leukemia. — Lymphatic  leukemia  is  an  exhausting  and 
fatal  general  disease,  characterized  by  profound  anemia,  an  enormous 
increase  in  the  white  corpuscles  of  the  blood,  particularly  the  lympho- 
cytes, and,  at  a  later  period,  by  enlargement  of  the  lymph  nodes  of 
the  body.  It  is  easily  distinguished  from  Hodgkin's  disease  by  the 
blood  count.  While  the  disease  is  invariably  fatal  in  the  end,  the 
judicious  use  of  the  .r-rays  will  often  bring  about  a  subsidence  of  all 
symptoms,  and  an  apparent  return  to  health  for  a  period  of  two  or 
more  years. 

Lymphosarcoma. — Lymphosarcoma  occurs  as  a  primary  or  a  second- 
ary affection.  Primary  lymphosarcoma  is  a  highly  cellular  growth 
occurring  in  lymphoid  tissue.  It  is  made  up  of  an  enormous  and 
rapid  growth  of  cells  that  closely  resemble  the  lymphoid  cells  of  the 
nodule,  but  are  slightly  larger,  and  contain  nuclei  rather  vesicular 
in  appearance  with  distinct  chromatin  granules  and,  in  rapidly  fixed 
tissues,  a  great  number  of  mitotic  figures.  The  structure  of  the 
nodes  is  entirely  lost  and  the  cells  are  seen  to  be  infiltrating  about 
the  periphery  of  the  node  into  the  surrounding  tissues.  It  occurs  in 
the  lymph  nodes,  in  the  tonsil,  in  the  lymphoid  tissues  of  the  intestines 
and  other  organs.  It  is  one  of  the  most  malignant  varieties  of  sarcoma. 
It  begins  usually  as  a  simple  enlargement  of  a  lymph  node  or  of  other 
lymphoid  tissue,  which  grows  rapidly  and  painlessly  at  first.  Later 
the  growth  infiltrates  surrounding  tissues,  painful  pressure-symptoms 
are  produced  and  metastases  occur.  Death  often  results  from  pressure 
on  important  organs  before  cachexia  has  had  time  to  develop.  The 
prognosis  is  grave.  Excepting  in  the  very  earliest  stages  treatment 
is  of  no  avail.  Early  and  thorough  removal  is,  however,  to  be 
recommended  as  the  only  chance  of  saving  life. 

Secondary  Sarcoma  and  Carcinoma. — Secondary  sarcoma  and  car- 
cinoma of  the  lymphatics  are  of  frequent  occurrence,  especially  the 
latter.  The  nature  of  these  processes  has  been  described,  and  will  not 
be  repeated  here.  Early  and  complete  removal  may  occasionally 
arrest  the  progress  of  the  growth. 


CHAPTER  XIII. 

INJURIES  AND  DISEASES  OF  THE  MUSCLES,  TENDONS, 
FASCLE  AND  BURS^E. 

INJURIES  OF  THE  MUSCLES,  TENDONS  AND  FASCLE. 

Contusions. — The  muscles  are  often  severely  contused  or  lacerated 
and  become  the  seat  of  more  or  less  extensive  extravasations  of  blood 
as  the  result  of  falls  or  other  injuries  which  do  not  break  the  skin. 
A  fi actuating  swelling  may  develop  if  the  extravasated  blood  is  local- 
ized, and — although  rarely — become  infected  and  converted  into  an 
abscess.  Ordinarily  the  extravasation  is  completely  absorbed  but 
occasionally  a  fibrous  scar  or  cyst  may  remain.  If  the  overlying 
fascia  is  injured  ecchymosis  develops;  otherwise  the  only  symptoms 
are  pain  and  soreness,  both  of  which  are  increased  by  motion  and 
relieved  by  rest  and  local  applications  of  heat  or  lead  and  opium. 

Rupture  of  Muscle  or  Tendon. — Rupture  of  a  muscle  or  tendon  may 
occur  as  a  result  of  severe  or  sudden  contraction,  any  atrophy  or 
degeneration  being  a  predisposing  factor.  The  injury  may  occur 
either  at  the  junction  of  the  muscular  and  tendinous  fibres,  through 
the  muscle  belly,  or  at  the  point  of  insertion  of  the  tendon,  and,  except 
in  the  latter  case,  may  be  accompanied  by  considerable  extravasation 
of  blood.  Rupture  of  the  quadriceps  extensor,  of  the  tendo  Achillis 
or  of  the  plantaris  comprise  those  most  commonly  seen.  "Lawn 
tennis  leg"  is  an  injury  not  infrequently  seen,  the  lesion  probably 
involving  the  gastrocnemius  with  or  without  plantaris.  "Rider's 
thigh"  is  a  similar  injury  to  the  abductor  muscles  of  the  thigh. 

Diagnosis. — The  diagnosis  is  made  by  the  occurrence  of  sudden 
acute  pain  during  a  severe  muscular  effort,  occasionally  accompanied 
by  an  audible  snap.  There  is  temporary  muscle  spasm  and  pain  which 
is  increased  by  attempted  motion.  If  the  rupture  is  complete  the 
function  of  the  muscle  is  lost,  contraction  causing  a  soft  swelling 
corresponding  to  the  belly  of  the  muscle,  without  resulting  motion 
in  the  part  to  which  it  is  attached.  During  contraction  a  depression 
may  be  felt  at  the  site  of  the  injury.  Considerable  extravasation  may 
develop,  involving  neighboring  joints  if  the  injury  has  extended  into 
the  capsule. 

Treatment. — The  treatment  depends  upon  the  site  of  the  injury  and 
the  extent  of  loss  of  function.  Slight  ruptures  are  probably  best 
treated  by  strapping,  followed  by  immediate  use  of  the  muscle,  thus 
preventing  secondary  tearing  due  to  contraction  of  muscle  fibres  during 
repair  with  the  limb  immobilized. 


INJURIES  OF  THE  MUSCLES,  TENDONS  AND  FASCIA       295 


If  large  muscles  or  tendons  are  torn  more  or  less  completely  across 
with  resulting  loss  of  function,  as  in  rupture  of  the  quadriceps  or  of  the 
tendo  Achillis,  repair  may  be  affected  by  rest,  approximating  the 
divided  ends  as  well  as  possible  with  adhesive  plaster.  More  often, 
however,  operative  treatment  (myorrhapy)  is  indicated,  the  injured 
parts  being  freely  exposed,  blood  clots  removed,  scar  tissue  removed 
if  the  rupture  is  an  old  one,  and  the  divided  tissues  carefully  sutured 
with  mattress  sutures  of  chromicized  catgut,  inserted  in  layers  if 
the  muscle  is  thick.  The  part  should  be  immobilized  in  a  position 
relaxing  the  injured  muscle.  The  operation  should  be  performed  under 
the  strictest  aseptic  technic,  particularly  if  a  joint  has  to  be  opened. 

Hernia  of  Muscle. — This  is  a  rare  condition,  following  injury  or 
disease,  and  consists-  in  the  protrusion  of  muscle  fibres  through  an 
opening  in  the  capsule.  The  herniated  fibres  form  a  tumor  which  is 
largest  when  the  muscle  is  at  rest  and  disappears  on  active  contraction. 
This  condition  is  to  be  differentiated  from  a  false  muscular  hernia, 
which  is  the  result  of  rupture  of  muscle  fibres,  the  resulting  tumor  not 
disappearing  when  the  muscle  is  contracted,  but  becoming  larger, 
harder,  and  moving  toward  the  point  of  origin  of  the  muscle. 

Treatment. — The  treatment  of  a  true  hernia  which  is  causing  symp- 
toms, is  operative;  the  tear  in  the  fascia  being  closed  with  catgut 
sutures,  the  edges  if  possible  being  undermined  and  overlapped. 
Occasionally  excision  of  the  protruding  portion  will  be  necessary. 

Wounds  of  Muscles  and  Tendons. — In  these  cases  the  possibility  of 
infection  must  always  be  kept  in  mind,  varying  considerably  with  the 
condition  of  the  patient's  skin  and  the  nature 
of  the  instrument  causing  the  injury.  The 
surrounding  skin  should  be  shaved,  and  then 
carefully  cleansed,  either  with  soap  or  tinc- 
ture of  iodine.  The  wound  should,  if  neces- 
san%  be  enlarged  so  that  its  depths  may  be 
thoroughly  exposed  and  any  foreign  material 
removed.  This  occasionally  requires  a  general 
anesthetic.  Strong  chemical  disinfectants 
should  not  be  used  because  of  their  harmful 
effect  on  tissue,  simple  cleansing  with  sterile 
salt  solution  usually  sufficing.  Severe  crush- 
ing injuries  require  the  most  careful  disinfec- 
tion, and  in  these  the  possibility  of  infection 
with  tetanus  bacilli  and  the  advisability  of 
a  prophylactic  injection  of  antitoxin  must 
always  be  considered.  Divided  muscles 
should  be  repaired  with  catgut  sutures,  the 

fascial  layers  partly  united  and  the  cutaneous  wound  closed,  drain- 
age being  always  provided  for,  either  with  rubber  tubes,  gauze 
packing,  rubber  tissue  or  strands  of  silkworm  gut.  The  extremity 
should  be  immobilized.     A  similar  procedure  should  be  undertaken 


Fig.  154. — Methods  of 
tendon  lengthening. 


296      INJURIES  OF  MUSCLES,   TENDONS,   FASCIA,   BURS& 

when  tendons  have  been  divided,  bearing  in  mind  the  fact  that 
the  tendon  ends  may  retract  a  considerable  distance  within  their 
sheaths.  The  ends  when  found  may  be  sutured  with  silk  or  fine 
ehromicized  catgut,  changing  the  position  of  the  limb  if  necessary  so 
as  to  bring  about  the  greatest  degree  of  muscular  relaxation.  Occa- 
sionally this  will  not  be  sufficient  to  allow  approximation  without 
tension,  and  in  this  case  the  tendon  may  be  lengthened  in  one  of  various 
ways,  or  the  ends  may  be  united  by  long  silk  sutures  which  act  as  a 
framework  into  which  the  tendon  gradually  grows.  Where  part  of  a 
tendon  has  been  destroyed  the  lengthening  operation  may  be  sufficient 
for  repair,  or  part  of  a  neighboring  tendon  of  a  less  important  muscle 
may  be  taken  and  grafted  to  fill  the  defect.  If  the  distal  end  of  a 
tendon  has  been  destroyed  the  proximal  end  may  be  sutured  into  the 
periosteum  as  near  as  possible  to  the  normal  site  of  insertion,  the 
periosteum  being  split,  the  tendon  end  inserted,  the  periosteum 
replaced  and  sutured  to  the  tendon. 

Tenorrhaphies  in  which  many  tendons  are  involved  are  long  and 
painstaking  operations  requiring  free  exposure  and  an  accurate  knowl- 
edge of  anatomy.  The  ultimate  success  of  an  operation  depends  largely 
upon  the  -maintenance  of  asepsis,  infection  being  often  followed  by 
sloughing  of  tendons.  Following  suture,  the  parts  should  be  immob- 
ilized for  two  weeks,  or  longer  in  the  case  of  grafting  operations,  to 
be  followed  by  gradually  increasing  passive  and  active  motion,  accom- 
panied by  massage  and  baking. 

Secondary  tenorrhaphies  following  non-repair  or  attempted  but 
unsuccessful  repair  of  divided  tendons  are  more  difficult  because  of 
retraction  and  adhesions. 

Dislocation  of  Tendons. — This  is  a  rare  condition,  occurring  usually 
as  a  result  of  trauma  or  sudden  strain.  In  the  majority  of  the  cases 
reported  the  peronei  have  been  involved,  usually  the  peroneus  longus, 
the  external  annular  ligament  being  torn  as  the  tendon  comes  out 
of  its  groove.  The  diagnosis  is  made  by  the  sudden  onset  of  localized 
pain  and  the  recognition  of  the  abnormal  position  of  the  tendon. 
Reduction  is  usually  easy  but  the  dislocation  tends  to  recur.  Occasion- 
ally rest  with  maintenance  of  reduction  by  pads  will  result  in  a  cure. 
In  other  cases  the  dislocation  causes  no  disability;  but  if  it  causes 
discomfort  it  may  require  operation,  replacing  the  tendon  and  holding 
it  in  place  by  suturing  ligament,  or  if  necessary  a  periosteum  and  bone 
flap  over  the  tendon  as  it  passes  behind  the  external  malleolus. 

DISEASES  OF  THE  MUSCLES. 

Myositis. — Myositis  may  be  either  simple  or  infectious  in  nature, 
and  occurs  as  a  result  of  contusions,  ruptures  or  infected  wounds,  from 
extension  from  a  neighboring  inflammatory  process  or  in  septicemia. 
It  occurs  also  as  a  part  of  the  pathologic  process,  in  parasitic  invasions 
as  trichiniasis.     The  symptoms  in  both  forms  are  pain  and  tenderness, 


DISEASES  OF  THE  MUSCLES  297 

with  a  stiff,  indurated  muscle.  In  the  suppurative  forms  a  localized 
abscess  develops  later.  The  non-suppurative  variety  may  be  treated 
by  rest  and  local  applications;  the  suppurative,  by  incision  and 
drainage. 

Acute  Primary  Myositis. — Acute  primary  myositis  is  a  rather  uncom- 
mon infection,  probably  due  to  a  staphylococcus,  in  which  the  local 
lesions  occur  in  the  muscles,  foci  of  inflammation  developing  which 
may  resolve  or  go  on  to  abscess  formation  with  practically  complete 
destruction  of  muscle  fibres.  Fulminating  cases  occur  with  rapid 
death  from  systemic  poisoning,  while  the  less  severe  cases  are  followed 
by  slow  recovery,  with  atrophy  and  contraction,  as  the  muscle  cells 
are  replaced  by  fibrous  tissue. 

Myositis  Ossificans* — Myositis  ossificans  is  a  rare  condition,  occurring 
chiefly  in  young  males,  in  which  there  is  a  development  of  bone  tissue 
in  the  muscles  accompanied  by  atrophy  of  muscle  fibres,  the  patient 
gradually  becoming  more  and  more  helpless.  There  is  no  curative 
treatment.  This  condition  should  not  be  confused  with  myositis 
ossificans  traumatica,  a  condition  in  which  as  a  result  of  repeated 
trauma  new  bone  forms  in  a  muscle,  usually  at  its  point  of  attachment 
to  the  peritoneum.  This  may  also  occur  following  a  single  trauma  such 
as  a  fracture,  osteogenetic  cells  being  displaced  outward  into  the  muscle 
tissue.    If  these  bony  masses  cause  symptoms  they  should  be  removed. 

Tuberculosis. — This  usually  occurs  by  direct  extension  from  neigh- 
boring foci  and  results  either  in  abscess  or,  if  the  tissues  are  more 
resistant,  in  sclerosis.  Metastatic  tuberculosis  of  muscles  is  very 
rare,  usually  follows  trauma  and  may  go  on  to  the  formation  of  cold 
abscess.  The  diagnosis  is  made  largely  by  exclusion,  or  the  finding  of 
tuberculous  lesions  in  other  parts  of  the  body  in  a  non-syphilitic 
patient  with  a  history  of  slight  muscular  pain  and  disability,  examina- 
tion showing  a  mass  in  the  muscle  tissue.  When  possible,  in  a  case  of 
this  sort,  excision  is  indicated  before  the  disease  has  extended  beyond 
one  muscle. 

Syphilis. — Syphilis  of  muscles  occurs  in  the  tertiary  stage  as  a 
diffuse  sclerosis  or  localized  gumma,  both  leading  to  contractions  and 
deformity.  The  sternomastoids  and  the  muscles  of  the  tongue  are 
most  often  involved.  Gummata  may  be  mistaken  for  sarcoma,  the 
diagnosis  resting  on  the  results  of  treatment. 

Atrophy. — This  may  be  simple  or  combined  with  fatty  or  amyloid 
degeneration.  It  occurs  as  a  result  of  disease,  following  myositis  and 
after  injuries  to,  or  diseases  of,  the  motor  nerves.  The  atrophic  muscles 
are  usually  soft  and  flabby,  occasionally  sclerosed,  and  are  frequently 
accompanied  by  deformities  due  to  the  unopposed  actions  of  the 
remaining  healthy  groups  of  muscles. 

New  Growths  of  Muscles. — New  growths  of  muscles  are  rare  as  pri- 
mary conditions  but  any  of  those  of  mesoblastic  origin  may  occur. 
Secondary  growths  are  more  common,  following  carcinoma  or  sarcoma. 
Fibromata  of  the  rectus  abdominis,   occurring  most  frequently  in 


298       INJURIES  OF  MUSCLES,   TENDONS,  FASCIA,  BURSA 

women  who  have  borne  children  are  known  as  desmoids.  The  treat- 
ment of  new  growths  of  muscles  should  be  governed  by  the  same 
principles  that  apply  to  new  growths  of  other  tissues. 

DISEASES  OF  THE  TENDONS. 

Tenosynovitis. — Inflammation  of  the  tendon  sheaths  has  been  taken 
up  in  the  section  on  Infections  of  the  Hand  and  Fingers,  page  222. 

Tumor  of  Tendon  Sheaths. — Any  of  the  connective-tissue  tumors 
may  occur,  growing  either  on  the  inner  or  outer  side  of  the  sheath. 
The  diagnosis  from  tuberculosis  may  be  difficult.  The  treatment  in 
all  cases  is  excision. 


^^ 


Fig.  155. — Ganglion  of  the  wrist. 

Ganglion. — Ganglia  are  small  cystic  tumors  usually  found  on  the 
dorsal  surface  of  the  wrist,  occasionally  on  the  flexor  surface  near  the 
metacarpophalangeal  joint,  rarely  on  the  dorsum  of  the  foot.  They 
occur  as  a  rule  in  young  individuals,  often  apparently  following  strain 
or  an  unusual  use  of  the  hand  or  arm.  At  one  time  they  were  thought 
to  be  hernial  protrusions  from  joints  or  tendon  sheaths,  but  the  work 
of  William  C.  Clarke  and  others  has  shown  that  they  are  the  result  of 
degenerative  processes  in  the  connective  tissue  about  the  joints  or 
tendon  sheaths,  collagenous  degeneration  being  followed  by  the  de- 
velopment of  thin-walled  cysts  containing  clear  serous  or  gelatinous 
fluid.  Secondary  communication  with  the  joint  cavities  or  tendon 
sheaths  may  develop.  Ganglia  rarely  cause  pain  but  occasionally 
patients  complain  of  a  sense  of  weakness  in  the  affected  part. 


DISEASES  OF  THE  FASCU2  299 

Treatment.  —  Small  ganglia  causing  no  symptoms  may  be  dis- 
regarded. Occasionally  a  cure  may  be  obtained  by  a  subcutaneous 
rupture  of  the  ganglion  by  means  of  a  blow  with  some  heavy  blunt 
instrument,  or  the  cyst  may  be  punctured  with  a  tenotome.  Either 
form  of  treatment  should  be  followed  by  firm  pressure,  with  a  pad  and 
bandage,  and  both  are  frequently  followed  by  recurrence.  The  most 
successful  treatment  consists  in  excision  under  strict  aseptic  precau- 
tions, as  the  joint  or  tendon  sheath  may  be  opened. 

Compound  palmar  ganglion  is  the  term  applied  to  a  distended  con- 
dition of  the  sheath  of  the  flexor  tendons  of  the  fingers  due  to  a  chronic 
tenosynovitis,  usually  tuberculous  in  nature. 


DISEASES  OF  THE  FASCIA. 

Fascial  Tuberculosis. — While  extension  of  tuberculous  process  to 
the  fasciae  and  muscles  surrounding  a  given  focus  is  often  seen,  fascial 
tuberculosis  may  also  occur  practically  as  an  independent  disease, 
arising  from  an  insignificant  glandular  focus  and  continuing  the  chief 
factor  in  a  given  case.  It  occurs  chiefly  in  the  neck,  axilla,  groin  and 
retroperitoneal  tissues  and  is  characterized  as  a  slowly  progressing 
inflammatory  process  with  thickening  and  induration  of  the  fascia 
and  intermuscular  septa.  Pain  is  rarely  prominent,  but  rigidity  may 
be  present.  The  process  may  remain  latent  or  break  down  and 
suppurate,  leaving  persistent  sinuses. 

Treatment. — The  treatment  should  consist  in  thorough  operative 
removal  of  the  diseased  tissue.  Occasionally  Beck's  paste  or  formalin 
and  glycerin  (2  per  cent.)  may  be  used  successfully  in  the  treatment 
of  sinuses  where  operation  is  contra-indicated. 

Dupuytren's  Contraction. — Dupuytren's  contraction  is  a  condition 
of  permanent  flexion  of  one  or  more  fingers  due  to  a  chronic  thickening 
and  contraction  of  the  palmar  fascia,  involving  especially  the  longitu- 
dinal fibres  extending  from  the  palm  to  the  tendon  sheaths  of  the 
fingers.  Microscopically  it  consists  in  the  general  formation  of  a  dense 
scar  involving  the  fascia  and  the  adjacent  connective  tissue  and  extend- 
ing to  the  joint  and  tendons.  It  is  more  common  in  men  over  middle 
age,  and  while  little  is  known  as  to  the  etiology,  it  has  been  ascribed 
to  trauma,  gout,  rheumatism,  arteriosclerosis,  syphilis  and  organic 
nervous  disease. 

Symptoms. — The  earliest  symptoms  are  the  appearance  of  small 
lumps  in  the  palm  followed  by  general  loss  of  extension  of  the  affected 
fingers  which  are  most  often  the  fourth  and  fifth. 

As  the  contraction  of  the  fascia  advances  the  finger  is  flexed  more 
and  more  sharply  until  the  tip  may  come  to  rest  against  the  palm  of  the 
hand  (Fig.  156) .  The  thickened  fascia  can  easily  be  felt  and  made  more 
tense  by  attempts  to  extend  the  fingers.  At  first  the  skin  is  movable 
over  the  fascia  but  later  becomes  adherent,  wrinkling  as  the  finger 


300      IX JURIES  OF   MUSCLES,   TEXDOXS,  FASCLE,   BURSA 

is  moved.  The  condition  is  progressive,  causing  increasing  deformity 
and  loss  of  function  and  is  often  bilateral,  although  generally  more 
advanced  on  one  side  than  on  the  other. 

Treatment. — In  the  early  stages  attempts  may  be  made  to  stop  the 
progress  of  the  disease  by  massage  and  the  use  of  splints,  but  as  a  rule 
operative  treatment  is  necessary.  This  may  consist  of  subcutaneous 
or  open  division  of  the  bands,  or  better,  of  complete  excision  of  the 
contracted  tissue  through  longitudinal  incisions.  In  some  cases  it 
has  been  suggested  that  the  skin  of  the  palm  and  the  entire  palmar 
fascia  be  removed  and  the  defect  filled  by  a  graft  from  the  chest  or 
thigh. 


Fig.  156. — Dupuytren's  contracture. 


INJURIES  AND  DISEASES  OF  THE  BURSA. 

The  bursa?  are  sacs  lined  by  synovial  membrane  located  at  points 
where  there  is  constant  or  intermittent  pressure  on  bone,  either  through 
the  action  of  tendons  or  through  external  agencies.  Bursa?  exist 
normally  in  certain  situations,  as  over  the  patella  or  olecranon,  and 
elsewhere  develop  as  the  result  of  long-continued  pressure  or  irritation, 
the  former  being  spoken  of  as  anatomic  and  the  latter  as  adventitious 
bursa?.  Some  of  the  bursa?  normally  communicate  with  the  adjacent 
joint  cavity,  others  occasionally  do  so,  while  the  majority  are  wholly 
independent  of  joints  or  other  synovial  sacs. 

Contusions. — These  are  the  result  of  trauma  and  usually  result  in 
a  hematoma  which  occasionally  breaks  down.  Over  bony  prominences, 
such  as  the  patella  or  olecranon,  they  may  make  the  diagnosis  of  a 
fracture  a  difficult  one.  The  symptoms  and  treatment  are  similar 
to  those  of  hematomata  elsewhere  in  the  soft  parts. 

Acute  Bursitis. — This  may  arise  following  trauma,  rheumatism, 
gonorrhea    or    direct    infection    through    a    wound.     The    symptoms 


INJURIES  AND   DISEASES  OF   THE  BCRS.E  301 

are  those  of  a  localized  inflammatory  process,  and  in  the  simple 
will  subside  with  rest  and  wet  applications.     The  suppurative  variety 
requires  incisioo  and  drainage,  with  occasional  secondary  operations 
to  destroy  persisting  secreting  tissue. 

Chronic  Bursitis. — Chronic  bursitis  may  arise  from  the  same  causes 
as  the  acute  condition,  in  the  majority  of  cases  following  mild  but  long- 
continued  trauma.  Tuberculosis  is  the  cause  in  a  certain  number  of 
cases.  In  the  traumatic  cases  the  fibrous  capsule  becomes  thickened 
and  an  excessive  amount  of  fluid  is  secreted,  distending  the  sac  and 
forming  a  globular  swelling.  In  tuberculosis  one  of  two  conditions 
may  predominate.  In  one  the  capsule  is  thickened  and  on  section 
presents  from  within  cut  ward  fibrin,  tuberculous  granulations  and 
dense  fibrous  tissue:  The  granulation  tissue  may  be  excessive  in 
amount,  forming  a  doughy  swelling  and  i-  prone  to  caseate  and  form  a 
cold  abscess.  In  other  cases  the  fluid  is  more  prominent,  and  occasion- 
ally coagulates  to  form  rice  bodies.  Syphilitic  bursitis  is  uncommon, 
usually  occurs  in  the  tertiary  stage,  forming  a  more  or  less  uodular 
swelling  of  the  diseased  bursa  which  i-  most  often  the  patellar. 

In  the  majority  of  cases  there  i>  little  pain  in  chronic  bursitis,  the 
symptoms  being  -imply  the  presence  of  a  globular  fluctuating  swelling 
over  the  site  of  the  bursa  with  more  or  less  stiffness  and  los>  of  function. 
The  differential  diagnosis  between  tuberculous  and  non-tuberculous 
bursitis  may  be  very  difficult.  Pain  may  or  may  not  he  a  prominent 
symptom,  depending  largely  upon  the  situation  of  the  bursa  and  the 
resulting  amount  of  pressure  to  which  it  i-  subjected. 

Treatment. — The  treatment  of  chronic  bursitis  in  general  con^t- 
in  removal  of  the  cause  of  inflammation  and  either  conservative  or 
operative  treatment  of  the  bursa  itself.  The  former  comprises  the 
various  forms  of  counter-irritation,  of  which  the  actual  cautery  is  the 
most  efficacious.  Among  the  operative  mea-ures  are  puncture,  followed 
by  pressure,  with  or  without  irritation  of  the  sac  wall  by  carbolic  acid 
or  the  tip  of  a  trocar;  incision  and  packing;  and  complete  excision. 
When  feasible  the  latter  is  the  best  form  of  operative  treatment, 
especially  if  there  is  any  possibility  of  tuberculosis. 

Subdeltoid  or  subacromial  bursitis  is  one  of  the  most  common  forms 
of  bursitis  and  one  of  the  most  frequent  pathological  conditions  about 
the  shoulder-joint. 

Codman  has  made  it  a  much  more  easily  recognized  condition,  as 
in  the  past  the  diagnosis  often  has  been  confused  with  chronic  arthritis, 
neuritis,  [muscular  rheumatism,  contusion  of  the  shoulder,  etc. 
The  disease  is  generally  traumatic  and  has  been  divided  by  Cod- 
man  into  three  types:  acute  or  spasmodic;  subacute  or  adherent, 
chronic  or  non-adherent.  In  all  the  types  the  symptoms  are  pain, 
usually  referred  to  the  insertion  of  the  deltoid  and  more  severe  at 
night,  accompanied  by  tenderness  below  the  tip  of  the  acromion  to 
the  outer  side  of  the  bicipital  groove,  inability  to  abduct  the  arm 
through  an  arc  of  more  than  ten  degrees  if  the  scapula  is  immobilized, 


302      INJURIES  OF  MUSCLES,   TENDONS,  FASCIA,  BURSM 

and  by  pain  on  attempted  external  rotation.  When  the  arm  is 
abducted  above  the  head,  tenderness  may  disappear,  the  bursa  passing 
upwards  beneath  the  acromion  out  of  reach  of  the  examining  finger. 
Stiffness  and  limitation  of  motion  become  more  marked  as  the  condition 
becomes  more  chronic,  motion  being  limited  by  adhesions  rather  than 
by  spasm,  as  in  the  acute  stages.  In  the  chronic  stage  without 
adhesions  motion  may  be  comparatively  free  but  painful  in  certain 
directions. 

Treatment. — In  the  acute  stage  treatment  should  consist  in  rest 
with  the  arm  abducted.  Prolonged  immobilization,  however,  will 
tend  to  the  formation  of  adhesions,  so  that  this  method  of  treatment 
should  not  be  too  long  continued.  As  the  acute  symptoms  subside, 
baking,  massage,  and  active  and  passive  motion  may  be  begun.  Cauter- 
ization often  gives  relief  from  pain  and  improves  function.  Occasion- 
ally forced  motion  under  anesthesia  with  the  object  of  rupturing 
adhesions  may  be  tried  but  adhesions  broken  in  this  way  are  very 
likely  to  reform.  Incision  of  the  bursa  with  division  of  the  bands, 
as  suggested  by  Codman,  is  the  preferable  procedure. 

Codman  has  reported  a  few  cases  in  which  symptoms  of  subacromial 
bursitis  have  been  simulated  or  caused  by  rupture  of  the  supraspinatus 
tendon,  with  good  results  following  operation. 

Albert's  Disease. — Albert's  disease  or  inflammation  of  the  bursa 
beneath  the  Achilles  tendon  is  a  condition  causing  pain  in  walking, 
especially  when  the  weight  of  the  body  is  raised  on  the  toes.  The 
bursa  may  be  felt  as  a  tender  swelling  above  the  attachment  of  the 
tendon  to  the  os  calcis.  It  i?  often  confused  with  an  inflammatory 
condition  of  the  tendon  itself  {tendinitis  Achilla  traumatica)  which 
may  follow  prolonged  walking,  bicycle  riding,  etc. 

Bunions. — Inflammation  in  the  bursa  over  the  metatarsophalangeal 
joint  of  the  great  toe  follow  ill-fitting  shoes  and  are  secondary  to  the 
bony  deformity  (hallux  valgus)  the  bursa  being  an  adventitious  one. 

Inflammation  of  the  bursa  about  the  hip  and  knee-joints  are  often 
the  cause  of  symptoms  simulating  joint  disease,  and  in  many  cases  are 
followed  by  or  associated  with  an  arthritis. 

Various  bursa?  such  as  the  olecranon,  prepatellar  or  ischial  are 
frequently  found  inflamed  in  certain  occupations,  and  to  these  names 
such  as  "housemaid's  knee,"  "miner's  elbow,"  etc.,  have  been  given, 
the  whole  group  being  classed  together  as  trade  bursitis. 

Treatment. — The  treatment  of  these  conditions  during  the  acute 
stage  consists  in  rest  and  cold  applications,  with  counter-irritation, 
and  if  necessary,  excision  when  the  chronic  stage  is  reached. 

Tumors  of  Bursas. — These  are  very  rare  conditions,  only  a  few 
having  been  reported,  all  of  the  connective-tissue  types.  They  should 
be  excised. 


CHAPTER  XIV. 
INJURIES  AND  DISEASES  OF  THE  NERVES. 

INJURIES  OF  THE  NERVES. 

Contusions. — A  nerve  trunk  may  be  contused  as  a  result  of  a  blow, 
a  fall,  or  any  other  trauma,  but  such  injuries  are  rare  from  the  fact 
that,  as  a  rule,  the  nerves  are  so  situated  as  to  be  protected  from 
external  violence.  The  nerves  most  exposed  to  such  injuries  are  the 
ulnar  at  the  elbow,  the  cords  of  the  brachial  plexus,  the  facial,  the 
sciatic,  the  external  popliteal,  and  the  anterior  tibial.  In  many 
instances  the  nerve  lesion  is  associated  with  a  fracture  or  dislocation. 

Symptoms. — The  symptoms  of  contusion  of  a  nerve  trunk  are  pain, 
a  feeling  of  tingling,  numbness,  or  the  sensation  of  pins  and  needles 
in  the  region  supplied  by  its  sensory  branches,  with  weakness  or 
paralysis  of  the  muscles.  The  symptoms  are  generally  temporary 
unless  the  injury  gives  rise  to  a  neuritis  or  degeneration  of  the  nerve 
fibres. 

Treatment. — Treatment  other  than  rest  is  rarely  necessary  for  this 
condition.  If,  however,  there  is  delay  in  restoration  of  function, 
counter-irritation  over  the  injured  area,  massage,  and  electricity  to 
the  region  of  its  distribution  are  to  be  employed. 

Wounds  of  Nerve  trunks. — These  injuries  are  of  fairly  common 
occurrence.  They  are  caused  by  fractures,  accidents  with  knives  or 
other  sharp  instruments,  cuts  from  glass,  gunshot  wounds,  and,  not 
infrequently,  accidental  division  takes  place  during  surgical  operations. 
As  a  result  of  such  injury  a  nerve  trunk  may  be  completely  divided 
or  it  may  be  simply  lacerated.  When  a  nerve  trunk  is  completely 
divided,  certain  changes  occur  in  its  peripheral  portion,  beginning  on 
the  second  or  third  day  and  continuing  for  three  or  four  weeks.  These 
changes  are  in  the  nature  of  a  degeneration,  and  consist  in  a  gradual 
destruction  of  the  myeline  and  the  axis-cylinders.  This  causes 
atrophy  of  the  nerve  and  degenerative  changes  in  the  muscles  supplied 
by  it.  These  changes  are  recognized  by  the  "  reaction  of  degeneration" 
in  the  affected  muscles,  which  is  indicated  by  certain  alterations  in  the 
reaction  of  the  muscles  to  the  electric  currents,  the  chief  change  being 
a  failure  of  the  muscle  to  respond  to  the  faradic,  and  occasionally 
an  exaggerated  response  to  the  galvanic  current.  The  proximal  end 
of  a  divided  nerve  trunk  becomes  gradually  thickened  and  presents  a 
bulbed  extremity,  made  up  of  connective  tissue  and  coiled  axis- 
cvlinders.     Occasionallv  in  uninfected  wounds  when  the  ends  of  a 


304  INJURIES  AND  DISEASES  OF   THE  NERVES 

divided  nerve  are  separated  by  a  short  interval  only,  repair  will  take 
place  with  more  or  less  complete  restoration  of  function,  as  evidenced 
by  a  return  of  sensation  after  neurotomy  or  even  neurectomy  for 
neuralgia.  Repair,  however,  takes  place  much  more  often  and  in  a 
far  more  satisfactory  manner  if  the  divided  ends  are  early  approximated 
by  open  operation  and  suture.  This  regeneration  of  injured  or 
divided  nerves  is  a  most  important  surgical  fact,  and  the  nature  of  the 
process  has  been  extensively  studied.  All  observers  agree  that  it  is 
possible  only  in  the  peripheral  nerves,  and  is  due  to  the  presence  of  the 
neurilemma.  Considerable  difference  of  opinion  exists  regarding  the 
nature  of  the  process,  many  holding  that  the  new  axis-cylinders 
develop  wholly  in  the  central  trunk  and  pass  downward  in  the  sheath 
of  the  peripheral  portion,  which  acts  as  a  scaffolding  or  conduit  for 
their  transmission.  Other  observers  believe  that  new  axis-cylinders 
develop  in  the  peripheral  portion  of  the  divided  nerve  from  a  prolifera- 
tion of  the  neurilemma  cells,  but  that  these  axis-cylinders  remain 
immature  and  functionless  until  they  unite  with  the  axis-cylinders  of 
the  central  end  of  the  nerve,  when  regeneration  becomes  complete. 
All  agree,  however,  that  the  condition  necessary  to  a  restoration  of 
function  is  early  and  accurate  coaptation  of  the  divided  ends. 

Symptoms. — The  symptoms  of  complete  division  of  a  nerve  trunk 
are  total  paralysis  of  the  muscles  supplied  by  it,  and  if  it  be  a  mixed 
nerve,  anesthesia  over  the  region  supplied  by  its  sensory  fibres.  The 
anesthesia  is  generally  incomplete  and  its  exact  limits  difficult  to 
determine,  owing  to  a  mixed  nerve  supply  in  most  cutaneous  areas, 
and  also  to  the  fact  that  a  region  of  total  anesthesia  when  present  is 
apt  to  be  surrounded  by  a  zone  of  diminished  sensibility.  The  reaction 
of  degeneration  is  to  be  looked  for  in  motor  nerves. 

Certain  trophic  disturbances  follow  the  division  of  a  nerve,  generally 
some  time  after  the  accident.  These  consist  first  in  hyperemia  over 
the  region  of  its  distribution,  which  later  is  succeeded  by  anemia 
of  the  part.  The  skin  becomes  shiny,  and  atrophied  (glossy  skin); 
the  nails  are  roughened,  present  furrows,  and  crack;  the  hairs  drop 
out  or  lose  their  color  and  lustre;  and  there  may  develop  an  extreme 
burning  sensation  which  causes  great  suffering. 

If  the  injury  to  the  nerve  is  simply  a  wound  or  laceration  without 
complete  division,  the  symptoms  may  be  those  of  a  contusion  with 
more  or  less  sensory  and  motor  paralysis,  generally  associated  with 
considerable  pain  at  the  point  of  injury  and  extending  over  the  course 
of  the  nerve. 

Incomplete  division  of  a  nerve  with  continued  irritation  of  the 
wounded  portion,  as  from  a  contracting  cicatrix,  is  apt  to  be  followed 
by  an  exaggerated  degree  of  pain  and  trophic  disturbance. 

Treatment. — Whenever  an  important  nerve  trunk  has  been  divided, 
the  treatment  should  be  union  of  the  divided  ends  by  suture  at  the 
earliest  possible  moment,  as  restoration  of  function  depends  in  great 
measure  upon  the  promptness  with  which  the  reparative  processes 


IS  JURIES  OF  THE  NERVES 


305 


are  inaugurated.     Doubtless  much  improvement  often  follows  late 
secondary  operations,  but  in  these  cases  the  improvement  is  apt  to  be 
greater    in   the   sensory   or   trophic   disturbances;    the   degenerated 
muscles  later  give  evidence  of  restoration  of  function  but  not,  as  a 
rule,  as  great  as  that  of  sensation.    In  recent  injuries  the  parts  should 
be  rendered  aseptic  by  the  usual  methods,  the  wound  sufficiently 
enlarged  to  give  a  satisfactory  exposure  of  the  divided  nerve,  which 
should  be  brought  together  and  held  by  one  or  more  catgut  or  fine 
silk  sutures.     If  the  ends  are  widely  separated,  they  should  be  well 
drawn  out  and  stretched  sufficiently  to  allow  easy  approximation 
without  tension.     This  is  always  possible  in  fresh  wounds  in  which 
there  has  been  no  loss  of  tissue.     After  the  nerve  has  been  sutured  it 
should  be  covered  by  a  layer  of  muscle,  fascia  or  fat,  to  prevent 
cicatricial  tissue  forming  about 
the  line  of  union,  and  the  wound 
closed  with  a  view  to  primary 
healing.      The    success    of   the 
operation  depends  very  largely 
upon  the  absence  of  infection. 
If  the  suture  has  been  success- 
ful,   an    improvement    in    the 
trophic  symptoms  will  be  first 
observed,  later  a  gradual  return 
of  sensation.     The  sensation  at 
first  will  be  abnormal  in  charac- 
ter, as  a  tingling  or  burning  in  the 
extremity,  followed  by  a  gradual 
progress    toward    the    normal. 
Motion  returns  later,  and  may 
not    be     complete     for     many 
months.     If    considerable  time 
has  elapsed  since  the  injury,  and 
the  primary  wound  has  healed, 
it  is  still  desirable  to  expose  and  suture  the  nerve,  although  the  result 
will  probably  be  less  perfect  than  in  operations  undertaken  at  an  earlier 
period.     An  incision  should  be  made  over  the  anatomic  line  of  the 
nerve,  and  its  divided  ends  located,  separated  from  the  surrounding 
adhesions,  and  drawn  toward  each  other.     The  bulbed  extremities 
are  to  be  excised  and  the  ends  approximated,  as  in  the  earlier  operation. 
If  the  ends  cannot  be  brought  together  without  tension,  the  incision 
should  be  extended,  and  a  further  attempt  made  to  stretch  the  nerve, 
both  from  above  and  below.     If  this  succeeds,  a  retention  suture  of 
chromicized  catgut  should  be  introduced  above  and  below,  from  one- 
quarter  to  one-third  of  an  inch  from  the  divided  ends,  and  drawn 
tightly  enough  to  bring  the  ends  in  easy  apposition;  they  should  then 
be  united  with  two  or  three  fine  catgut  or  silk  sutures,  preferably 
passed  only  through  the  sheath  (Fig.  157) .     If  coaptation  is  impossible, 
20 


Fig.  157. — Methods  of  nerve  suturing: 
A,  B,  sutures  passing  through  sheath  and 
part  of  nerve;  C,  sutures  through  sheath, 
reinforced  by  relaxation  suture  through 
entire  nerve. 


30G  IX. JURIES  AND  DISEASES  OF   THE  NERVES 

the  nerve  may  be  grafted  by  the  insertion  of  a  section  of  nerve  from 
a  freshly  killed  rabbit  or  dog,  or  one  removed  from  a  recently  ampu- 
tated limb;  or  the  nerve  may  be  lengthened  by  flaps  cut  from  the  upper 
and  lower  portions  and  united  as  in  tendon  suture  (Fig.  158).  Passing 
numerous  strands  of  catgut  between  the  divided  ends  by  means  of 
a  fine  curved  needle  has  been  recommended,  also  enclosing  the  strands 
within  a  tube  of  decalcified  bone  or  a  small  section  of  a  formalinized 
artery  which  also  surrounds  the  nerve  for  a  short  distance  above  and 
below.  In  all  of  these  plans  the  intermediary  substances  simply 
serve  as  conductors  of  the  new  axis-cylinders,  and  afford  protection 
against  the  formation  of  scar  tissue  between  the  divided  ends  of  the 
nerve. 

That  these  are  the  essential  elements  in  successful  nerve  suture 
is  evidenced  by  the  experiments  of  Forsman,  who  found  that  if  he 
placed  the  divided  ends  of  a  nerve  in  a  straw  tube  regeneration  took 
place,  but  was  slow.  If,  however,  the  ends  of  the  nerve  were  connected 
by  a  thread,  or  the  lumen  of  the  straw  filled  with  brain  substance,  the 
repair  was  far  more  rapid. 

After  healing  of  the  operative  wound  the  affected  region  should  be 
treated  by  massage,   hot  and  cold  douches,   and   electricity.     The 


Fig.  158. — Nerve  suture  with  lengthening. 

judicious  use  of  these  measures  will  often  retard  degenerative  changes 
in  the  muscles. 

Compression  of  Nerve  trunks. — Permanent  compression  of  a  nerve 
trunk  is  generally  caused  by  contraction  of  a  cicatrix,  pressure  of  a 
displaced  bone  or  callus  following  dislocation  or  fracture,  or  to  growth 
of  a  tumor  or  aneurism.  The  symptoms  are  variable.  There  may  be 
simply  the  numbness  and  muscular  weakness  of  a  contusion,  or  the 
impairment  of  function  may  progress  until  total  paralysis  of  sensation 
and  motion  occurs.  Pain  is  often  a  prominent  symptom.  The 
treatment  should  consist  in  removal  of  the  cause  of  the  pressure. 
Dissecting  the  nerve  free  from  an  encircling  cicatrix  or  mass  of  callus, 
or  the  removal  of  fragments  of  bone  or  a  neighboring  tumor,  will  often 
bring  about  a  permanent  cure,  although  a  return  of  sensation  and 
motion  may  be  delayed,  as  after  more  severe  injuries. 

Among  the  most  frequently  observed  traumatic  palsies  are  those 
of  the  facial  muscles  due  to  injury  to  the  seventh  nerve  from  fracture 
at  the  base  of  the  skull,  those  of  the  extensor  muscles  of  the  forearm 
due  to  pressure  on  the  musculospiral  nerve,  from  fracture  of  the 
humerus,  ulnar  paralyses  from  fractures  of  the  internal  condyle  of 
the  humerus,  and  paralyses  of  the  leg  muscles  from  fractures  about  the 
knee-joint,  causing  pressure  on  the  popliteal  nerves. 


DISEASES  OF  THE  NERVES  307 


DISEASES  OF  THE  NERVES. 


Neuritis. — Neuritis  is  an  inflammation  of  the  sheath  of  a  nerve 
trunk  and  of  the  connective  tissue  between  its  fasciculi.  It  arises  from 
a  variety  of  causes,  some  of  which  are  not  well  understood.  Trauma, 
wound  infection,  pressure,  general  sepsis,  the  infectious  diseases,  gout, 
rheumatism,  alcoholism,  lead  poisoning,  and  other  chronic  toxemias 
are  generally  enumerated  among  the  causes  of  this  condition.  The 
disease  may  be  limited  to  a  single  trunk,  or  a  very  large  number  of 
nerves  may  be  affected,  giving  rise  to  a  serious  condition  known  as 
multijjlc  neuritis.  In  the  former  there  is  generally  present  well-marked 
thickening  and  edema  of  the  trunk,  in  the  latter,  chiefly  degenerative 
changes. 

Symptoms. — The  symptoms  of  neuritis  vary  with  the  cause  of  the 
disease  and  the  acuteness  of  the  attack.  A  neuritis  following  an  acute 
trauma  or  due  to  extension  of  a  septic  process  to  the  tissues  of  the 
nerve,  may  give  rise  to  severe  pain  radiating  over  the  area  of  distribu- 
tion of  the  nerve,  with  localized  tenderness,  and  to  the  presence  of  a 
hard  tender  cord  if  the  nerve  is  superficially  located.  In  less  acute 
cases  the  symptoms  may  be  simply  a  numbness  or  the  sensation  of 
pins  and  needles  over  the  affected  area,  followed  by  a  gradually  develop- 
ing anesthesia  with  trophic  disturbance.  In  motor  nerves  there  will 
be  muscular  paresis  or  paralysis,  often  with  atrophy  and  the  reaction 
of  degeneration.  In  certain  eases  of  acute  neuritis  the  process  is  an 
ascending  one,  and  may  eventually  involve  a  plexus  or  the  spinal 
cord.  When  the  inflammation  reaches  the  plexus,  symptoms  will 
appear  in  the  other  branches  of  distribution;  when  the  cord  becomes 
involved,  symptoms  of  myelitis  are  present. 

Treatment. — The  treatment  of  neuritis  is  almost  entirely  medical, 
and  should  consist  in  absolute  rest  of  the  part  if  the  pain  is  severe, 
with  counter-irritation  over  the  course  of  the  nerve.  Later  the  use  of 
massage,  baths,  and  electricity  is  to  be  recommended  to  favor  the 
processes  of  repair  and  to  prevent  wasting  of  the  muscles.  Con- 
stitutional conditions,  as  gout,  rheumatism,  or  syphilis,  shculd  receive 
appropriate  treatment.  If  sepsis  or  pressure  is  found  to  be  an  etiologic 
factor,  it  should  be  removed  surgically.  Another  surgical  measure 
which  is  frequently  of  benefit  in  chronic  cases,  especially  where  trophic 
ulcerations  are  present,  is  nerve-stretching.  It  is  desirable  to  pre- 
vent secondary  muscular  contractions  by  the  use  of  splints  or  other 
mechanical  apparatus. 

Neuralgia. — Neuralgia  is  a  condition  characterized  by  severe  radiat- 
ing pain  following  the  course  of  a  sensory  or  mixed  nerve,  unaccom- 
panied by  evidences  of  inflammation  or  systemic  disturbance.  The 
pain  may  be  continuous  or  intermittent.  When  intermittent,  the 
paroxysms  may  occur  as  often  as  every  two  or  three  minutes,  or  the 
intervals  may  be  prolonged  to  several  hours  or  days.  Each  paroxysm 
may  be  characterized  by  a  sudden,  acute,  darting  pain,  which  may 


308  INJURIES  AND  DISEASES  OF  THE  NERVES 

be  the  cause  of  convulsive  movements  in  the  neighboring  muscles 
(especially  in  neuralgia  of  the  fifth  nerve),  and  may  as  suddenly 
cease;  or  the  pain  may  begin  with  a  slight  discomfort  which  gradually 
increases  in  severity  until  the  most  acute  suffering  is  produced,  and 
then  suddenly  or  gradually  subsides.  Patients  suffering  from  neu- 
ralgia may  have  a  series  of  attacks  extending  over  a  period  of  several 
days  or  weeks  and  then  be  free  for  a  number  of  months. 

Etiology. — The  causes  of  neuralgia  are  obscure.  Apparently  it  is 
often  due  to  malaria,  rheumatism,  gout,  syphilis,  or  lead  poisoning, 
but  quite  as  often  it  occurs  without  association  with  any  of  these 
toxemic  conditions.  General  ill-health  from  any  cause,  and  especially 
anemia,  seem  often  to  be  associated  with  neuralgia.  Of  the  local 
causes,  trauma,  irritation  of  one  of  the  peripheral  branches  of  a  nerve, 
pressure  from  any  cause,  and  exposure  to  cold  and  dampness,  are  the 
most  frequent.  Faulty  nutrition  of  a  nerve  trunk  or  ganglion  from 
an  obliterating  endarteritis  of  the  minute  vessels  of  the  sheath  not 
infrequently  leads  to  degenerative  changes  which  may  account  for  the 
impaired  function  of  the  nerve.  This  has  been  observed  particularly 
in  the  Gasserian  ganglion  in  severe  cases  of  tic  douloureux. 

Diagnosis. — In  the  diagnosis  of  neuralgia  one  should  remember 
that  much  confusion  has  arisen  by  the  careless  manner  in  which 
the  terms  neuralgia  and  neuritis  have  been  used.  While  both  con- 
ditions give  rise  often  to  chronic  pain  over  the  distribution  of  certain 
sensory  or  mixed  nerves,  one  should  limit  the  term  neuritis  to  those 
cases  in  which  some  gross  evidence  of  an  inflammatory  process  is 
present,  as  tenderness  or  thickening  over  the  course  of  the  nerve, 
more  or  less  continuous  pain,  aching  or  discomfort,  muscular  weakness, 
trophic  disturbance,  or  evidence  of  degeneration.  In  pure  neuralgia 
none  of  these  symptoms  are  present,  the  pain  is  sharp,  stabbing,  and 
paroxysmal,  with  intervals  of  complete  freedom  from  abnormal 
sensations.  Pressure  over  a  nerve  which  is  the  seat  of  neuralgia  will 
often  give  a  certain  measure  of  relief,  while  the  same  pressure  over  the 
nerve  in  a  case  of  neuritis  will  increase  the  suffering.  It  must  be 
admitted,  however,  that  in  certain  cases  both  conditions  seem  to  be 
associated. 

Treatment. — In  the  majority  of  instances  the  treatment  of  neuralgia 
falls  to  the  care  of  the  physician  rather  than  the  surgeon.  Iron, 
quinine,  salicin,  cod-liver  oil,  and  good  food,  associated  with  the 
local  use  of  heat,  menthol,  or  other  soothing  applications,  will  be  found 
useful  in  the  treatment  of  most  cases  in  which  the  cause  is  obscure 
Large  doses  of  aconite  or  strychnine  have  been  advised,  and  hydro- 
therapy or  a  change  of  climate  will  often  be  of  great  benefit.  For  the 
immediate  relief  of  pain  the  use  of  aspirin,  phenacetine,  acetanilid, 
or  some  of  the  other  coal-tar  analgesics,  or  opium  in  some  form,  is 
frequently  necessary.  Galvanism  is  often  effectual.  When  these 
measures  are  unsuccessful  and  the  suffering  is  great,  surgical  inter- 
vention is  indicated.     Neuralgia  is  treated  surgically  by  the  removal 


DISEASES  OF  THE  NERVES  309 

of  a  direct  cause,  as  the  pressure  of  a  tumor,  cicatrix,  or  foreign  body 
upon  the  nerve;  or  by  the  removal  of  a  reflex  cause,  as  the  treatment 
of  carious  teeth,  intranasal  conditions,  disease  of  the  accessory  sinuses, 
or  of  ovarian,  renal,  rectal,  vesical,  or  urethral  sources  of  irritation; 
by  nerve-stretching  in  neuralgia  of  a  mixed  nerve;  by  neurotomy, 
neurectomy,  or  the  injection  of  alcohol,  osmic  acid,  or  other  chemical 
substances  into  the  nerve  trunk  with  a  view  to  producing  degenerative 
changes,  in  disease  of  a  purely  sensory  nerve. 

Nerve-stretching. — This  is  applicable  to  disease  of  any  accessible 
nerve-trunk,  but  is  employed  most  frequently  in  sciatica.  The 
nerve  should  be  exposed  by  an  incision,  carefully  separated  from 
the  neighboring  tissues,  surrounded  by  the  bent  finger,  a  strand  of 
gauze,  or  a  blunt  hook,  and  progressively  increasing  traction  made 
for  four  or  five  minutes,  after  which  the  wound  is  closed  and  an  aseptic 
dressing  applied.  Temporary  improvement  almost  always  follows 
this  procedure,  and  permanent  relief  is  sometimes  obtained.  The 
sciatic  nerve  may  also  be  stretched  by  the  dry  method,  by  placing 
the  patient  on  his  back  and  forcibly  flexing  the  thigh  on  the  body, 
the  leg  being  held  in  complete  extension.  Roman  von  Baracz,  in  a 
recent  article,  asserts  that  in  obstinate  cases  of  sciatica  adhesions 
frequently  exist  between  the  trunk  of  the  nerve  and  the  tissues  at 
or  just  within  the  sciatic  notch,  and  advises  exposing  the  nerve  at  this 
point  and  separating  the  adhesions  with  the  finger.  Bennet  and 
Niordano  have  successfully  resected  the  posterior  roots  of  the  nerve 
in  rebellious  sciatica. 

Neurotomy  and  neurectomy  have  been  largely  employed  in  the 
treatment  of  neuralgia.  Division  of  a  nerve-trunk  gives  instant 
relief  to  neuralgic  pains  in  its  branches,  but  recurrences  are  frequent 
after  this  operation,  due  to  a  subsequent  union  of  the  divided  ends. 
Removal  of  a  section  of  a  nerve-trunk,  leaving  a  considerable  interval 
between  the  divided  ends,  which  may  be  filled  with  sterilized  paraffin, 
rubber  tissue,  or  some  other  unirritating  substance,  is  more  successful, 
but  the  symptoms  recur  not  infrequently  after  these  procedures. 

Tic  Douloureux. — Of  all  the  different  forms  of  neuralgia,  the  cases 
most  likely  to  fall  to  the  care  of  the  general  surgeon  are  those  affecting 
the  various  branches  of  the  fifth  cranial  nerve,  and  grouped  under  the 
term  tic  douloureux.  If  the  disease  is  limited  to  one  of  the  three 
divisions  of  the  nerve,  neurotomy,  neurectomy,  or  alcohol  injection 
may  be  practised.  Of  these  procedures,  the  last  two  only  are  to  be 
recommended.  If  the  disease  affects  all  three  divisions  of  the  nerve, 
or  if  the  disease  has  resisted  all  other  rational  methods  of  treatment, 
and  the  symptoms  are  so  severe  as  to  warrant  the  patient  assuming  a 
considerable  risk  to  obtain  relief,  intracranial  neurectomy  or  removal 
of  the  Gasserian  ganglion  is  to  be  recommended. 

Neurectomy  of  the  First  Division  of  the  Fifth  Nerve. — The  supra- 
orbital nerve  is  exposed  by  a  horizontal  incision  just  below  the  superior 
margin  of  the  orbit,  dividing  the  tissues  down  to  the  supra-orbital 


310  INJURIES  AND  DISEASES  OF   THE  NERVES 

notch,  through  which  the  nerve  passes.  The  nerve  is  then  grasped 
by  an  artery-clamp  and  separated  from  the  surrounding  orbital 
fat,  which  is  depressed  by  a  flat  retractor.  Traction  is  then  made 
upon  the  nerve  until  the  supratrochlear  branch  is  exposed.  The 
nerve  is  divided  behind  this  branch  and  the  peripheral  portion  removed. 
The  wound  is  then  closed  and  an  aseptic  dressing  applied. 

Neurectomy  of  the  Second  Division. — Expose  the  infra-orbital 
nerve  by  a  curved  horizontal  incision  along  the  lower  margin  of  the 
orbit.  The  nerve  will  be  found  passing  out  of  the  infra-orbital  foramen 
lying  on  the  levator  labii  superioris  muscle.  It  should  be  grasped  with 
an  artery-clamp  or  a  piece  of  stout  silk  tied  around  it.  The  orbital 
periosteum  and  fat  should  be  retracted  and  the  canal  broken  open  by  a 
chisel,  the  nerve  drawn  outward,  divided  as  far  back  as  possible,  and 
the  peripheral  portion  removed,  after  which  the  wound  should  be 
united  and  dressed.  A  far  more  complete  but  more  difficult  operation 
is  that  suggested  by  Carnochan.  Expose  the  infra-orbital  region  by  a 
T-incision,  the  perpendicular  arm  extending  from  the  infra-orbital 
notch  to  a  point  near  the  angle  of  the  mouth,  the  horizontal  arm  along 
the  inferior  margin  of  the  orbit.  Next,  isolate  the  nerve  as  it  emerges 
from  the  foramen  and  secure  it  with  a  piece  of  strong  silk;  then  divide 
all  tissues  down  to  the  bone  and  arrest  bleeding.  Next  remove 
a  portion  of  the  anterior  wall  of  the  antrum  with  a  chisel  or  trephine, 
and  then  remove  a  small  button  from  the  posterior  wall  with  a  one-half 
inch  trephine,  exposing  the  sphenomaxillary  fossa.  The  infra-orbital 
canal  is  then  opened  from  below  by  a  chisel  or  bone-forceps,  throughout 
its  entire  length,  after  which  the  nerve  is  drawn  downward  into  the 
trephine-opening  through  the  posterior  wall  of  the  antrum,  and  followed 
backward  to  the  foramen  rotundum.  It  should  be  divided  as  near  the 
foramen  as  possible,  and  the  entire  extracranial  portion  removed, 
including  the  sphenopalatine  or  Meckel's  ganglion.  Considerable 
venous  hemorrhage  will  accompany  the  manipulations  in  the  spheno- 
maxillary fossa,  which  is  best  controlled  by  packing.  The  packing 
may  be  allowed  to  remain  in  place  two  or  three  days,  and  after  its 
removal  the  cutaneous  wound  can  be  sutured  without  anesthesia,  as 
all  sensation  in  the  part  has  been  abolished  by  the  operation. 

Neurectomy  of  the  Third  Division. — Make  a  curved  incision  around 
the  angle  of  the  jaw,  dividing  only  the  skin  and  superficial  fascia; 
isolate  the  two  main  branches  of  the  facial  nerve  and  Stenson's 
duct,  which  lie  on  the  fascia  covering  the  masseter  muscle,  retract 
these  structures  and  separate  the  fibres  of  the  masseter  muscle,  exposing 
the  ascending  ramus  of  the  jaw.  Next  trephine  this  just  above  the 
angle  and  locate  the  nerve  as  it  enters  the  dental  canal.  Divide  it  as 
close  to  the  canal  as  possible,  grasp  the  proximal  end  with  forceps, 
and  follow  it  upward  for  an  inch  or  more,  and  divide  with  blunt 
scissors.     Unite  the  cutaneous  incision  and  apply  an  aseptic  dressing. 

As  recurrences  after  these  peripheral  neurectomies  were  of  frequent 
occurrence,  Thiersch,  in  1889,  advocated  a  more  thorough  removal 


DISEASES  OF  THE  NERVES  311 

of  the  nerve  trunk  by  evulsion.  His  method  consisted  in  exposing 
the  nerve  by  the  usual  method,  seizing  it  with  a  pair  of  forceps,  and, 
by  a  slow  twisting  motion,  to  evulse  both  the  central  and  peripheral 
portions. 

Moschcowitz  has  recently  reviewed  the  subject,  and  has  demon- 
strated by  personal  observation  and  by  referring  to  numerous  reports 
of  others,  both  clinical  and  experimental,  that  the  cause  of  a  recurrence 
of  the  symptoms  after  all  peripheral  operations  is  a  regeneration  of 
the  nerve,  which  can  be  demonstrated  by  a  re-exposure  of  the  site  of 
the  original  operation.  He  logically  concludes  that  the  only  method 
of  preventing  a  recurrence  is  to  introduce  an  effective  barrier  to  the 
passage  of  the  newly  developed  nerve  fibres  through  the  bony  canal. 
For  this  purpose  he.  suggests  the  use  of  blunt-pointed  silver  tacks, 
which  can  be  firmly  driven  into  the  various  foramina,  or  of  silver  foil 
or  dentist's  amalgam,  with  which  a  bony  canal  can  be  plugged. 

The  Injection  Methods. — The  injection  into  a  bony  nerve  canal 
or,  still  better,  into  the  nerve  trunk  of  1  c.c.  of  a  1  per  cent,  solution 
of  osmic  acid  has  been  followed  by  relief  in  many  cases  as  reported  by 
Bennett,  Murphy,  and  others.  The  method  consists  in  exposing  the 
nerve  at  the  foramen  of  exit  and  injecting  the  solution  by  means  of  a 
hypodermic  syringe.  The  contact  of  the  acid  blackens  the  tissues, 
and  for  that  reason  the  surrounding  skin  should  be  protected. 

The  injection  of  80  per  cent,  alcohol  into  and  about  the  nerve  trunks 
has  recently  been  advocated  by  Schlosser  and  others.  The  results 
which  have  followed  this  method  have  been  encouraging.  Kiliani 
has  reported  55  personal  cases,  of  which  47  were  definitely  relieved. 
He  makes  no  claim  to  permanency  of  result,  but  suggests  that  recur- 
rences can  be  easily  treated  in  the  same  manner.  The  injections 
are  made  by  means  of  a  syringe  and  a  long,  blunt,  or  acutely  bevelled 
needle.  No  anesthesia  is  required,  and,  by  a  reasonable  degree  of 
anatomic  knowledge  and  skill  all  of  the  peripheral  foramina  and  even 
the  rotundum  and  ovale  can  be  reached.  About  1.5  c.c.  of  80  per  cent, 
alcohol,  with  or  without  the  addition  of  a  small  amount  of  cocaine, 
is  injected  into  the  foramen.  If  successful,  the  injection  should 
immediately  be  followed  by  a  burning  pain  over  the  area  of  distribution 
of  the  nerve,  later  by  numbness  and  anesthesia. 

When  all  peripheral  methods  fail,  or  in  cases  of  severe  neuralgia, 
involving  two  or  all  three  branches  of  the  nerve,  one  of  the  intracranial 
methods  is  to  be  recommended.  Three  operations  are  to  be  considered : 
Removal  of  the  Gasserian  ganglion,  division  of  its  sensory  root,  or 
section  of  the  second  and  third  branches  with  the  interposition  of  a 
folded  strip  of  rubber  protective  tissue  or  some  other  substance  to 
prevent  regeneration. 

Intracranial  Neurectomy  or  Removal  of  the  Gasserian  Ganglion. — 
The  Gasserian  ganglion  may  be  exposed  by  the  Hartley-Krause 
operation.  Make  an  omega-shaped  incision  extending  from  the 
anterior  extremity  of  the  zygoma  upward  and  backward  along  the 


312 


INJURIES  AND  DISEASES  OF   THE  NERVES 


temporal  ridge  to  its  posterior  extremity  (Fig.  159).  Carry  the 
incision  down  to  the  skull,  arrest  hemorrhage,  and  divide  the  bone 
in  the  line  of  this  incision,  using  a  surgical  engine,  or  the  Gigli  saw 
through  several  small  trephine-openings,  care  being  taken  not  to  wound 
the  dura.  The  flap,  consisting  of  the  bone  adherent  to  the  soft  parts, 
is  then  raised  with  periosteal  elevators  and  broken  off  along  the  line 
of  its  base,  which  should  be  just  opposite  the  zygoma.  The  middle 
meningeal  artery  may  be  injured  by  separating  the  bone  from  the 
dura  and  should  be  secured  by  a  fine  silk  ligature  passed  beneath  the 
dura  with  a  small  curved  needle.  The  lower  margin  of  the  opening 
into  the  skull  may  be  extended  by  removal  of  the  thin  plate  of  bone 
with  rongeur  forceps.  When  all  hemorrhage  is  arrested  and  the 
position  of  the  head  is  so  adjusted  as  to  admit  the  greatest  amount  of 


Fig.  159.  —  Osteoplastic  flap  turned  down,  exposing  the  dura  mater  and  middle 
meningeal  artery.  The  brain  and  dura  are  then  pushed  upward  so  as  to  expose  the 
petrous  bone  with  the  ganglion  lying  on  its  apex.    (Hartley.) 

light,  the  dura  is  very  slowly  and  very  gently  raised  from  the  middle 
fossa  of  the  skull  by  the  fingers  or  a  smooth  gauze  sponge,  until  the 
foramina  (rotundum  and  ovale)  are  exposed.  When  these  are  freely 
exposed,  the  dura  and  brain  are  well  retracted  by  means  of  a  flat 
highly  polished  spatula,  and  the  second  and  third  divisions  of  the  nerve 
drawn  upward  on  a  small  blunt  hook  and  divided  as  close  to  the  bone 
as  possible.  The  proximal  portions  of  the  two  nerves  are  then  secured 
by  two  artery-clamps,  the  dura  divided  between  the  nerves  along  the 
thin  curved  edge,  made  prominent  by  upward  traction  on  the  clamps, 
and  the  sheath  of  the  ganglion  opened.  The  ganglion  is  removed  by 
twisting  the  two  clamps  so  as  to  tear  the  branches  and  the  attached 
ganglion  backward  away  from  the  untouched  first  division.  The 
difficulties  of  this  operation  are  chiefly  from  severe  and  long-continued 


DISEASES  OF  THE  NERVES  313 

venous  hemorrhage  from  small  and  large  dural  trunks  emptying  into 
the  cavernous  sinus  or  from  a  wound  of  the  sinus  itself.  This  generally 
can  be  controlled  by  gauze  packing,  irrigating  the  wound  with  hot 
salt  solution,  or  both  combined.  The  operator  should  be  provided 
with  a  large  number  of  conveniently  sized  strips  of  gauze,  which  may 
be  used  for  packing  the  apex  of  the  wound,  allowed  to  remain  a  minute 
or  two  and  then  removed.  Raising  the  patient  to  the  sitting  posture 
and  the  application  of  adrenalin  to  the  bleeding  point,  will  sometimes 
be  of  service.  After  removal  of  the  ganglion  and  arrest  of  the  hemor- 
rhage the  bone-flap  should  be  replaced  and  secured  with  silkworm- 
gut  sutures,  a  small  rubber  tissue  drain  being  left  in  one  angle  of  the 
wound.  The  eye  should  be  protected  by  a  small  layer  of  sterile  cotton 
covered  by  several  layers  of  gauze,  the  wound  dressed,  and  the  whole 
held  in  place  by  a  snug  head  bandage  of  starched  crinoline. 

Harvey  W.  Cushing  exposes  the  ganglion  by  a  lower  incision  simi- 
larly curved.  The  temporal  muscle  and  zygoma  are  divided  in  the 
line  of  the  incision,  and  both  are  turned  downward,  exposing  the 
lower  portion  of  the  temporal  fossa  of  the  skull.  This  is  broken 
through  with  a  chisel  and  the  opening  enlarged  with  the  rongeur 
forceps.  The  dura  with  the  middle  meningeal  artery  is  gently  retracted 
and  the  ganglion  exposed,  as  in  the  Hartley  operation.  The  advan- 
tages of  this  route  are  that  there  is  little  or  no  risk  of  wounding  the 
middle  meningeal  artery,  and  as  the  opening  in  the  skull  is  nearer 
the  ganglion,  its  exposure  can  be  accomplished  with  a  minimum  amount 
of  retraction  and  compression  of  the  brain  (Fig.  160). 

By  means  of  this  incision  one  is  also  able  to  expose  the  second 
and  third  divisions  as  they  emerge  from  their  foramina,  and  thus 
perform  an  extracranial  neurectomy. 

Spiller  and  Frazier,  in  1901,  suggested  as  a  substitute  for  complete 
removal  of  the  ganglion  simply  section  of  the  posterior  sensory  root. 
The  ganglion  is  exposed  by  the  Hartley  or  Cushing  method,  the  foramen 
ovale  recognized,  and  an  incision  made  in  the  dura  from  the  foramen 
backward  over  the  sensory  root,  great  care  being  taken  to  avoid 
wounding  the  middle  meningeal  artery  as  it  emerges  from  the  foramen 
spinosum.  The  dura  is  next  stripped  from  the  posterior  portion  of  the 
ganglion  and  the  sensory  root  until  the  latter  is  sufficiently  exposed 
to  enable  the  operator  to  surround  it  with  a  blunt  hook.  The  root 
is  then  drawn  forward  and  divided,  evulsed,  or  a  small  portion  resected. 
The  wound  is  then  closed,  as  described  above,  and  an  aseptic  dressing 
applied. 

Cushing  has  recently  adopted  this  method,  and  believes,  with 
Frazier,  that  the  procedure  is  quicker,  safer,  and  as  effectual  as  removal 
of  the  entire  ganglion.  Frazier  states  that  it  is  possible  in  most  of 
these  cases  to  avoid  division  of  the  motor  root. 

A  still  less  hazardous  operation  is  the  one  described  by  Abbe  in 
the  Annals  of  Surgery,  Jan.,  1903.  It  consists  in  exposing  the  ganglion, 
severing  the  second  and  third  divisions,  and  preventing  reunion  by 


314 


INJURIES  AND  DISEASES  OF   THE  NERVES 


placing  a  folded  piece  of  rubber  protective  tissue  over  the  foramina. 
This,  in  cases  in  which  the  neuralgia  is  limited  to  the  second  and 
third  divisions  of  the  nerve,  is  often  effectual.  Mixter  introduces 
dentists'  amalgam  into  the  foramina,  and  is  strong  in  his  endorse- 
ment of  the  procedure. 


■JVXjrt*  ^tt\.t;*wvjw^.mB^«„ 


K^< 


Fig.  160. — Showing  relations  of  the  middle  meningeal  artery  to  the  operative  foramen 
before  and  after  elevation  of  the  dura  and  exposure  of  the  ganglion.     (Cushing.) 


In  exposing  the  ganglion  for  any  of  these  procedures,  if  the  Cushing 
method  is  used,  some  embarrassment  occasionally  will  be  encountered 
by  the  presence  of  an  elevated  ridge  of  bone  just  external  to  the  foramen 
ovale  and  somewhat  anterior  to  it.      This  in  brachycephalic  skulls 


DISEASES  OF  THE  NERVES  315 

is  not  infrequently  so  well  marked  as  to  hide  the  ganglion  when 
approached  by  the  low  operation.  When  present,  the  summit  of  the 
elevation  can  be  chiselled  off  without  difficulty  and  a  perfect  exposure 
secured. 

When  the  entire  ganglion  is  removed,  trophic  changes  are  apt 
to  appear  in  the  cornea,  which,  unless  great  care  is  used,  lead  often 
to  ulceration  and  destruction  of  the  eyeball. 

To  avoid  this  complication,  the  eye  should  be  protected  against 
all  irritation  or  trauma  during  the  operation,  and  at  its  completion 
should  be  douched  with  boric'  acid  solution,  closed,  covered  with 
a  pad  of  sterile  cotton,  and  protected  by  a  separate  bandage.  This 
dressing  should  be  removed  daily  after  the  first  forty-eight  hours  and 
the  eye  carefully  wrashed  and  resealed. 

Tumors  of  the  Nerves. — Tumors  arising  from  nerve  trunks  are  rare. 
They  are  generally  of  mesoblastic  origin,  and  arise  from  the  sheath  of 
the  nerve  or  the  connective  tissue  between  the  fasciculi.  The  tumors 
most  frequently  encountered  are  the  fibromata  or  fibroneuromata, 
myxomata,  and  sarcomata.  A  fibroma  growing  from  the  sheath  of  a 
nerve  may  produce  no  symptoms,  as  the  nerve  fibres  may  pass  along 
one  side  of  the  tumor  as  a  well-recognized  cord  and  be  in  nowise 
affected  by  its  growth.  Occasionally,  when  the  pressure  on  the  neigh- 
boring parts  produces  compression  of  the  nerve  fibres,  pain,  numbness, 
and  muscular  disturbances  are  produced.  This  is  especially  true  if 
the  tumor  develops  in  a  bony  canal.  Fibromata  growing  from  the 
interfascicular  areolar  tissue  may  cause  a  separation  of  the  individual 
fibres  of  the  nerve,  which  may  be  spread  out  over  its  surface. 

A  well-recognized  form  of  fibroma  is  the  painful  subcutaneous 
tubercle,  which  often  appears  along  the  branches  of  the  cutaneous 
nerves,  especially  on  the  lower  leg.  The  condition  known  as  molluscum 
fibrosum  is  in  many  instances  a  group  of  fibromata  growing  from  the 
cutaneous  nerves.  Fibroneuromata  are  tumors  which  contain  nerve- 
elements  as  well  as  fibrous  tissue,  and  are  commonly  observed  in  the 
bulbed  extremity  on  the  proximal  end  of  a  divided  nerve  trunk. 

Sarcomata  and  myxomata  are  rare,  and  are  recognized  by  the 
usual  characteristics  of  these  growths. 

Treatment. — In  regard  to  treatment,  the  same  rules  apply  as  in 
tumors  of  other  tissues.  Malignant  tumors  should  be  removed  as 
early  as  possible;  innocent  tumors  giving  rise  to  painful  symptoms 
should  also  be  removed.  Small  fibromata  occurring  on  important 
nerve  trunks,  not  giving  rise  to  symptoms  and  showing  no  tendency 
to  increase  in  size,  should  not  be  molested. 

Tic  Convulsif. — This  affection  is  a  spasmodic  twitching  of  the  facial 
muscles  due  to  irritation  of  the  seventh  nerve.  Its  cause  is  obscure. 
It  is  often  associated  with  severe  neuralgia  of  the  fifth  nerve.  If  the 
disease  is  of  a  severe  type  and  causes  much  discomfort,  stretching 
the  seventh  nerve  will  sometimes  afford  relief.  The  nerve  is  best 
exposed  by  the  method  of  Baum,  which  consists  in  a  curved  incision 


316 


INJURIES  AND  DISEASES  OF  THE  NERVES 


beginning  behind  the  ear  opposite  the  external  meatus  and  carried 
downward  and  forward  around  the  lobule  toward  the  angle  of  the 
jaw.  The  anterior  border  of  the  sternomastoid  muscle  is  exposed 
and  retracted  backward,  and  the  parotid  gland  drawn  forward.  This 
exposes  the  digastric  muscle,  along  the  upper  border  of  which  the  nerve 
will  be  found.  It  is  raised  on  a  blunt  hook  and  the  tension  maintained 
for  two  or  three  minutes,  after  which  the  wound  is  closed.  In  the 
severest  cases,  or  in  those  in  which  nerve-stretching  has  not  afforded 
relief,  division  of  the  main  trunk  of  the  nerve  at  its  exit  from  the 
stylomastoid  foramen  and  anastomosis  with  the  spinal  accessory 
or  hypoglossal  is  indicated.  Successful  cases  have  been  reported  by 
dishing  and  Kennedy. 


Fig.  161.— Torticollis.     (Whitman.) 


Torticollis. — Torticollis  is  a  spasmodic  contraction  of  the  sterno- 
mastoid muscle  alone  or  associated  with  other  muscles  of  the  neck, 
producing  an  abnormal  attitude  of  the  head  with  or  without  convulsive 
movements  (Fig.  161).  The  disease  occurs  both  as  a  congenital 
and  an  acquired  affection.  In  the  congenital  variety  the  cause  is 
often  a  hematoma  of  the  sternomastoid  muscle  or  a  prenatal  myositis, 
with  subsequent  contraction  from  atrophy  of  the  muscular  fibres  and 
the  formation  of  dense  connective  tissue.  In  the  acquired  variety 
the  symptoms  are  often  apparently  due  to  some  central  irritation 
transmitted  through  the  nerves  supplying  the  affected  muscles.  It  is 
frequently  associated  with  neurasthenia,  hysteria,  and  other  neuroses; 


DISEASES  OF  THE  NERVES  317 

occasionally  it  is  thought  to  follow  trauma.  In  the  congenital  myel- 
ogenous variety,  cervical  scoliosis  and  asymmetry  of  the  skull  and  face 
are  frequently  present.  Cases  seek  relief  from  the  surgeon  only  after 
medical  means  have  been  exhausted. 

Treatment. — The  surgical  treatment  consists  in  tenotomy,  myotomy, 
stretching  or  division  of  the  spinal  accessory  nerve,  or  division  of  the 
posterior  branches  of  the  upper  three  cervical  nerves.  In  the  con- 
genital cases,  where  the  muscle  is  found  to  be  converted  into  a  dense 
fibrous  band,  the  operation  of  Mikulicz  is  to  be  recommended.  This 
consists  in  exposure  of  the  muscle  by  a  longitudinal  incision,  division 
of  its  sternal  and  clavicular  attachments,  and  complete  removal  of 
the  degenerated  portion,  if  necessary,  as  far  as  the  mastoid  process. 
After  closure  of  the  wound  the  position  of  the  head  should  be  over- 
corrected  and  held  by  a  plaster-of- Paris  cast. 

In  the  spasmodic  variety  nerve-stretching  or  neurectomy  is  indicated. 
The  spinal  accessory  nerve  can  be  exposed  by  a  three-inch  incision 
along  the  anterior  margin  of  the  sternomastoid  muscle,  beginning  at 
the  tip  of  the  mastoid.  The  incision  is  carried  down  to  the  deep 
fascia,  which  is  divided,  and  the  space  between  the  muscle  and  the 
carotid  sheath  exposed  by  retracting  the  tissues.  The  nerve  will 
be  found  just  below  the  posterior  belly  of  the  digastric  muscle  at  a  point 
where  the  latter  crosses  the  transverse  process  of  the  atlas,  and  is 
identified  by  following  it  downward  to  the  sternomastoid  muscle, 
which  it  enters  at  a  point  opposite  the  angle  of  the  jaw.  The  nerve  is 
raised  on  a  blunt  hook  and  may  be  stretched  or  a  portion  resected. 
The  nerve  also  may  be  reached  by  an  incision  along  the  middle  of  the 
posterior  border  of  the  muscle  as  it  passes  into  the  trapezius.  Bailey 
has  pointed  out  that  complete  paralysis  of  the  sternomastoid  and 
trapezius  occasionally  follows  this  operation,  owing  to  the  entire 
nerve  supply  being  transmitted  through  the  spinal  accessory  trunk. 
If  the  posterior  muscles  of  the  neck  are  largely  involved,  the  trapezius, 
splenius,  complexus,  and  trachelomastoid,  the  posterior  branches 
of  the  first,  second,  and  third  cervical  nerves  should  be  divided. 
This  is  accomplished  through  an  incision  five  or  six  inches  in  length 
extending  from  the  occiput  vertically  downward  about  an  inch  from 
the  spinous  processes.  The  incision  should  divide  the  skin,  fascia,  and 
trapezius  muscle;  the  edges  of  the  muscle  should  then  be  well  retracted 
and  the  splenius  and  complexus  divided  transversely.  The  posterior 
muscular  branches  of  the  three  upper  cervical  nerves  will  be  found 
beneath  the  complexus.  These  should  be  resected  and  the  divided 
muscles  united  with  catgut  sutures.  After  closure  of  the  wound  the 
head  should  be  placed  in  its  normal  position  and  retained  by  means  of 
a  plaster-of-Paris  dressing.  After  healing  of  the  wound,  massage, 
regular  exercises,  hydrotherapy,  and  general  tonic  measures  should  be 
employed. 

Perforating  Ulcer  of  the  Foot. — Perforating  ulcer  of  the  foot  is  an 
indolent  ulcer  occurring  generally  under  the  ball  of  the  great  toe,  and 


318  INJURIES  AND  DISEASES  OF   THE  NERVES 

showing  no  disposition  to  heal  even  under  the  most  favorable  con- 
ditions. The  causes  of  this  disease  are,  first,  a  condition  of  more  or 
less  complete  anesthesia  of  the  skin,  associated  with  frequently  repeated 
traumata;  some  interference  with  the  trophic  nerve  control  of  the  part, 
or  both  of  these  conditions  may  be  combined.  The  disease  is  there- 
fore often  associated  with  tabes,  syringomyelia,  and  spina  bifida. 
It  is  also  occasionally  encountered  in  diabetic  or  alcoholic  subjects 
who  suffer  from  neuritis.  The  surrounding  skin  is  often  anesthetic; 
the  ulcer  may  extend  to  the  bone  and  not  infrequently  results  in 
necrosis. 

Treatment. — The  treatment  consists  in  rest  and  elevation  of  the 
part,  hot  poultices  or  wet  dressings,  with  curettage  of  the  ulcer  and 
removal  of  the  thickened  skin,  followed  by  packing  with  balsam  or 
iodoform  gauze.  If  these  measures  fail,  stretching  the  sciatic  or 
internal  popliteal  nerve  may  be  tried.  In  the  more  obstinate  cases 
amputation  may  be  necessary.  If  in  a  diabetic  subject,  a  proper 
diet  should  be  prescribed  and  the  urine  rendered  sugar-free  when 
the  ulcer  in  most  cases  will  heal. 


OPERATIONS  ON  THE  NERVES. 

Resection  of  the  Cervical  Sympathetic  for  Glaucoma  or  Exophthal- 
mic Goitre. — This  operation  is  still  on  trial  for  these  and  other  con- 
ditions. Sufficient  data  are  not  at  hand  to  allow  us  to  determine  its 
value. 

The  upper  three  cervical  ganglia  with  the  connecting  cord  may 
be  exposed  by  an  incision  made  along  the  entire  length  of  the  posterior 
border  of  the  sternomastoid  muscle.  After  division  of  the  deep 
fascia  and  retraction  inward  of  the  muscle  the  carotid  sheath  is  exposed. 
beneath  which  will  be  seen  the  gray  cord  of  the  sympathetic  nerve. 
This  should  be  followed  upward  and  downward  until  the  ganglionic 
enlargements  are  found  and  the  cord  divided  above  the  first  and  below 
the  third  ganglion. 

Nerve  Anastomosis. — The  success  which  attended  nerve  suture  in 
traumatic  cases  naturally  led  to  the  employment  of  nerve  anastomosis 
with  a  view  to  restoring  function  in  peripheral  nerves  which  have 
been  rendered  functionless  by  trauma  or  disease  (Fig.  162). 

Facial  Paralysis. — As  facial  palsy  is  one  of  the  most  frequent  and 
most  disfiguring  of  the  motor  palsies,  this  was  one  of  the  first  to  receive 
the  serious  attention  of  surgeons.  In  1895  Mr.  Ballance,  of  London, 
performed  the  first  facio-accessory  anastomosis.  Since  that  time 
numerous  cases  have  been  reported  by  Gushing,  Korte,  and  others, 
with  satisfactory  restoration  of  function  in  the  paralyzed  nerve. 
Faeiohypoglossal  anastomosis  is  advocated  by  Frazier,  Taylor,  and 
others,  who  report  equally  satisfactory  results.  In  all  of  these  cases 
during  the  period  of  gradual  restoration  of  function,  associated  move- 


OPERATIONS  OS    THE  NERVES 


319 


ments  occur  in  the  region  formerly  supplied  by  the  active  nerve  trunk, 
when  voluntary  motion  is  attempted  in  the  facial  group  of  muscles. 

Operations  should  not  be  undertaken  in  Bell's  palsy  or  non-traumatic 
paralysis  of  the  facial  nerve  for  at  least  six  months  after  the  onset  of 
the  symptoms,  as  cases  are  known  to  recover  spontaneously  up  to  that 
period.  In  traumatic  cases  the  earlier  the  operation  is  performed  the 
better,  although  recoveries  are  reported  by  these  operations  many 
years  after  the  injury. 

The  technic  of  the  operation  is  comparatively  simple.  The 
region  is  exposed  by  a  longitudinal  incision  along  the  anterior  border 


Fig.   162. — Nerve  anastomosis:     A,  intact    nerve;    B,    paralyzed    nerve;    I,  lateral 
anastomosis  (peripheral  implantation) ;    II,  lateral   anastomosis  (central  implantation). 


of  the  sternomastoid  muscle,  the  facial  trunk  recognized  at  its  exit 
from  the  stylomastoid  foramen,  and  followed  well  into  the  substance 
of  the  parotid  gland  until  its  bifurcation  is  reached.  The  spinal 
accessory  is  next  exposed  for  a  distance  of  two  or  three  centimeters 
proximal  to  its  entrance  into  the  under  surface  of  the  sternomastoid 
muscle.  The  two  nerves  are  then  divided  and  an  end-to-end  suture 
practised,  as  shown  in  Fig.  163,  the  proximal  end  of  the  accessory 
being  joined  to  the  distal  extremity  of  the  facial.  If  the  hypoglossal 
is  employed,  the  technic  is  a  little  more  difficult,  as  the  nerve  lies 
deeper.     Some  surgeons  prefer  to  employ  only  a  part  of  the  functionat- 


320 


INJURIES  AND  DISEASES  OF  THE  NERVES 


ing  nerve  for  the  anastomosis;  others  graft  the  peripheral  end  of  the 
facial  into  the  accessory  or  hypoglossal,  making  an  end-to-side  anasto- 
mosis (Fig.  162).  In  all  cases  the  union  should  be  protected  by  wrap- 
ping it  in  Cargile  membrane,  a  bit  of  fascia,  muscle,  or  fat.  As  success 
depends  very  largely  upon  primary  union  of  the  wound,  the  operation 


XV ^ 

Fig.  163. — Illustrating  method  of  facio-accessory  anastomosis.     (Harvey  Cushing.) 


should  not  be  undertaken  unless  the  surgeon  can  command  trained 
assistants  and  the  conditions  necessary  for  a  perfect  aseptic  technic. 

Brachial  Nerve  Paralysis. — Brachial  nerve  paralysis  of  traumatic 
origin  occurs  most  frequently  as  a  birth  palsy.  It  is  more  rarely  met 
with  in  later  life  as  a  result  of  an  injury  which  forcibly  separates  the 
head  and  shoulder,  or  as  the  result  of  a  gunshot  or  stab  wound.     In 


OPERATIONS  ON  THE  NERVES 


321 


some  cases  of  birth  palsy  the  roots  of  the  plexus  are  actually  torn  apart; 
in  others  the  nerve  trunks  are  so  stretched  as  to  cause  a  rupture 


K    3 

iS  o 

.3  "° 


-So 


a  c3 
.2H 


of  the  sheath  and  some  of  the  fibres,  with  hemorrhage  and  the  later 
formation  of  dense  scar  tissue,  which  effectually  prevents  nerve 
regeneration. 


21 


322 


INJURIES  AND  DISEASES  OF   THE  NERVES 


In  the  milder  cases  only  the  fifth  root  is  injured;  in  the  more  severe 
injuries,  the  sixth,  seventh,  and  eighth  roots;  or,  in  the  severest,  the 
entire  plexus  may  be  torn  from  the  spinal  column.  In  all  of  these 
cases  a  more  or  less  complete  paralysis  of  the  upper  extremity  results. 
A  study  of  Fig.  164  will  enable  one  to  estimate  the  extent  of  a  given 
injury  from  the  grouping  of  the  paralyzed  muscles. 

In  the  treatment  of  brachial  birth  palsy,  at  least  six  months  should 
elapse  before  operation  is  performed,  as  a  spontaneous  recovery 
occurs  in  a  certain  proportion  of  the  cases. 


Fig.  165. — 1,  scalenus  anticus  muscle;  2,  phrenic  nerve;  3,  internal  jugular  vein;  4, 
transversalis  colli  artery  divided;  5,  seventh  cervical  root;  6,  omohyoid  muscle;  7, 
fifth  cervical  root;  8,  scalenus  medius  muscle;  9,  sixth  cervical  root;  10,  transversalis 
colli  artery;  11,  suprascapular  nerve;  12,  nerve  to  subclavius  muscle;  13,  clavicle; 
14,  nerve  to  scalenus  anticus  muscle.     (Taylor,  Clark,  and  Prout.) 

The  operation  consists  in  exposing  the  plexus  by  an  oblique  incision 
from  the  posterior  border  of  the  sternomastoid  outward  to  the  acromio- 
clavicular articulation.  The  incision  is  gradually  deepened,  the 
omohyoid  muscle  retracted  or  divided,  and  the  plexus  exposed,  as 
seen  in  Fig.  165.  The  further  steps  of  the  operation  are  to  be  deter- 
mined by  the  lesions  found.  If  one  or  more  of  the  roots  or  trunks  are 
completely  severed,  an  attempt  should  be  made  to  suture  them  after 
removal  of  their  bulbed  extremities.  If  this  is  impossible,  an  attempt 
should  be  made  to  anastomose  live  proximal  trunks  and  the  functionless 
distal  branches.  When  the  plexus  is  apparently  intact,  indurated 
areas  should  be  sought  for  and  excised,  and  suture,  or  anastomosis, 
carried  out  to  restore  function.     After  these  procedures  have  been 


OPERATIONS  ON  THE  NERVES  323 

completed,  the  wound  should  be  closed  and  dressed,  and  the  head  and 
shoulder  approximated  to  relieve  all  tension  on  the  anastomosed  nerves. 
Successful  operations  have  been  reported  by  Kennedy,  Taylor,  and 
others.  The  nature  of  the  injury  is  such  that  a  complete  restoration 
of  function  is  seldom  to  be  expected,  and  the  number  of  carefully 
reported  cases  is,  as  yet,  too  small  to  enable  one  to  make  any  definite 
statements  regarding  prognosis.  p]nough  has  been  demonstrated, 
however,  to  give  rise  to  much  encouragement  in  the  surgical  treatment 
of  these  otherwise  hopeless  and  distressing  conditions. 

Infantile  Paralysis. — Infantile  paralysis  has  recently  been  successfully 
treated  by  nerve  anastomosis;  also  paralysis  of  muscles  of  the  upper 
and  lower  extremities,  due  to  destruction  of  nerve-trunks  from  com- 
pound fractures,  lacerated  wounds,  and  other  forms  of  trauma.  The 
principles  to  be  followed  in  all  of  these  cases  are  the  same  as  in  the 
conditions  described  above. 

When  possible,  the  distal  trunk  of  the  functionless  nerve  should 
be  anastomosed  into  the  undivided  trunk  of  a  normal  nerve  by  drawing 
the  freshly  divided  end  of  the  peripheral  nerve  into  a  longitudinal  slit 
in  the  normal  trunk,  and  securing  it  in  place  by  sutures  passed  through 
its  sheath. 


CHAPTER  XV. 
INJURIES  AND  DISEASES  OF  HEAD  AND  BRAIN. 


ANATOMY  OF  THE  SCALP. 

The  skull  is  covered  everywhere  by  soft  parts,  and  depending  on 
the  situation,  the  constituent  parts  of  this  covering  vary.  Over  the 
vertex  of  the  skull  stretches  the  scalp  which  is  divided  into  the  non- 
hairy  and  hairy  scalp.  This  is  composed  of  five  layers:  the  skin, 
subcutaneous  fat,  aponeurosis  or  muscle,  areolar  tissue,  and  periosteum 
(Fig.  166). 


CEREBRAL   VEIN 


[fc-CI 

MM  subcutaneous 

TISSUE 

APONEUROSIS 
SUBAPONEUROTIC    TISSUE 
PERICRANIUM 

SAGITTAL    SUTURE 
PARIETAL    BONE 

TWO    LAYERS    OF    DURA 
LONGITUDINAL    SINUS 


FALX    CEREBRI 


Fig.  166. — Frontal  section  of  scalp  and  skull  through  the  sagittal  suture  and  the  superior 
longitudinal  sinus.     (Woolsey.) 

1.  The  skin  may  contain  numerous  hairs  which  are  gathered  together 
somewhat  roughly  in  groups  of  three  to  five,  leaving  a  space  in  between 
which  is  free  from  hairs.  The  extent  over  which  the  hair  is  present 
varies  with  individuals  and  age.  The  scalp  also  contains  sweat  and 
sebaceous  glands  and  small  muscles,  the  erector  pili.  Beneath  the 
skin  there  is  a  layer  containing 

2.  Subcutaneous  fat,  which  is  arranged  within  the  spaces  of  a  fibrous 
meshwork,  the  trabecule  of  which  run  for  the  most  part  perpendicular 
to  the  surface.  There  are  numerous  bloodvessels,  the  main  supply 
of  the  scalp,  which  run  in  these  trabecule  adherent  to  them  by  their 
outer  surfaces.  These  trabecule  bind  the  scalp  to  the  aponeurosis 
beneath. 


ANATOMY  OF  THE  SCALP 


325 


3.  The  aponeurosis  is  a  strong,  fibrous  sheet  of  tissue  which  extends 
from  the  occipitalis  muscle  behind,  forward,  to  the  frontalis  muscle 
in  front.  It  is  attached  laterally  to  both  the  skin  and  the  temporal 
fascia  and  gradually  breaking  up  into  various  layers,  the  fat  at  the 
same  time  becoming  more  like  that  in  the  rest  of  the  body. 

4.  The  loose  areolar  tissue  binds  the  aponeurosis  to  the  underlying 
periosteum.  It  is  so  elastic  that  it  permits  the  free  movements  on  the 
skull  which  the  scalp  enjoys. 

5.  The  periosteum  is  loosely  adherent  to  the  bone.  It  is,  however, 
firmly  attached  along  suture  lines,  and  this  is  especially  true  in  the  very 


Fig.  167. — Diagram  showing  cutaneous  areas  of  nerve  distribution  of  face  and  scalp. 

(Gray.) 

young  and  the  newborn.  This  attachment  is  due  to  the  processes  of 
the  periosteum  which  project  into  the  interstices  of  the  sutures. 

The  bloodvessels,  both  veins  and  arteries,  run  in  the  trabecule 
of  fibrous  tissue  in  the  subcutaneous  fatty  tissue.  The  arteries 
anastomose  freely  one  with  another  in  all  parts  of  the  scalp.  The 
veins  communicate  with  those  within  the  skull  by  means  of  the  various 
emissary  veins,  the  more  constant  of  which  are  the  parietal  and  the 
mastoid.  There  is  also  a  communication  via  the  angular  and  the 
ophthalmic  in  the  orbit. 

The  nerves  of  the  scalp  are  derived  for  the  most  part  from  the  fifth 
cranial  pair  through  the  following  branches:  frontal,  supra-orbital, 


326         INJURIES  AND  DISEASES  OF  HEAD  AND  BRAIN 

superficial  temporal,  auriculotemporal;   also  the  occipitalis  major,  a 
branch  of  the  cervical  plexus  (Fig.  107). 

The  lymphatic  radicals  are  collected  into  various  large  trunks  and 
pass  to  the  different  groups  of  nodes  as  follows: 

1.  The  frontal  region,  includes  the  bridge  of  nose,  forehead,  eyebrows 
and  region  anterior  to  the  coronal  suture,  and  the  vessels  from  here 
pass  to  the  parotid  glands  situated  anterior  to  the  external  auditory 
meatus  and  angle  of  jaw. 

2.  The  parietal  or  temporal  region  group  is  divided  into  two 
divisions — an  anterior  and  a  posterior.  They  drain  the  region  from 
the  coronal  suture  posterior  for  a  variable  distance,  not,  however,  so 
far  as  the  external  occipital  protuberance.  The  anterior  group  pass 
to  the  parotid  glands,  the  posterior  to  the  mastoid  glands. 

3.  The  occipital  drain  the  remaining  posterior  region  of  the  scalp 
and  may  be  subdivided  into  two  groups,  an  external  and  an  internal. 
The  external  drain  the  more  anterior  portions  of  the  occipital  region 
and  converge  into  a  constant  large  single  trunk  which  passes  down  to 
one  of  the  sternomastoid  glands  in  the  neck.  The  internal  group, 
on  the  other  hand,  pass  to  the  occipital  glands  and  then  pass  to  the 
sternomastoid  group. 

INJURIES  OF  THE  SCALP. 

Injuries  to  the  soft  parts  of  the  head  may  be  either  contusions, 
wounds,  avulsions  or  burns. 

Contusions. — Contusions  of  the  scalp  are  classified  according  to 
their  situation,  into:   subcutaneous,  subaponeurotic  or  subperiosteal. 

Subuctaneous  contusions  of  the  scalp  are  caused  by  blows  of  a  blunt 
instrument  striking  the  head,  or  by  falls  whereby  the  head  strikes  some 
hard,  blunt  object.  The  trauma  is  not  sufficient  to  rupture  the  outer 
layer  of  the  skin  but  causes  a  tear  and  rupture  of  the  bloodvessels 
in  the  skin  and  in  the  subcutaneous  fatty  areolar  tissue.  The  blood  is 
extravasated  into  the  surrounding  areolar  tissue  and  tends  to  gravitate 
to  the  most  dependent  portions,  which  accounts  for  the  appearance 
of  ecchymosis  and  edema  of  the  eyelids  following  contusions  of  the 
vertex  or  frontal  regions.  When  a  large  artery  is  ruptured  the  blood 
may  accumulate  very  rapidly  and  give  rise  to  a  hematoma  which  at 
times  has  been  known  to  pulsate.  When  the  blood  accumulates 
between  the  aponeurosis  and  the  periosteum  due  to  the  rupture  of  the 
vessels  in  the  loose  tissue  binding  these  two  structures  together  we 
have  a  subaponeurotic  hematoma,  while  with  the  accumulation  beneath 
the  periosteum  stripping  it  away  from  the  skull  we  have  a  subperiosteal 
hematoma.  The  two  last  varieties  are  apt  to  be  circumscribed  and 
surrounded  by  a  firm  dense  encircling  border  of  coagulated  fibrin 
while  the  centre  remains  soft  or  even  fluctuating.  This  condition  may 
simulate  very  closely  a  depressed  fracture  of  the  skull,  the  ridge  of 
coagulated  fibrin  being  mistaken  for  the  edge  of  the  fracture.     The 


PLATE    XI 


Posterior 

auricular 

glands 

Occipital 
glands 


Maxillary  glands 


— Parotid  glands 
Buccinator  glands 


Suprama  ndibu  la  r 

glands 
Submaxillary 

glands 

Submental  glands 


Inferior  deep 
cervical  glands 


Superficial   Lymph    Glands  and  Lymphatic  Vessels  of  Head 
and  Neck.     (Gray.) 


INJURIES  OF  THE  SCALP  327 

mistake  may  be  avoided  by  exerting  slow,  continuous  pressure  on  the 
ridge,  when  it  will  be  made  to  disappear  and  one  may  then  pass  the 
finger  continuously  from  the  bone  beneath  the  softened  central  portion 
to  the  surrounding  skull  without  encountering  any  inequalities  or 
depressions. 

Process  of  Healing. — In  the  subcutaneous  and  subaponeurotic 
varieties  the  extravasated  blood  is  eventually  absorbed  and  leaves  no 
trace,  but  often  in  the  subperiosteal  variety  there  is  a  formation  of  new 
bone  about  the  periphery  where  the  periosteum  has  been  raised,  and 
this  remains  as  a  permanent  thickened  area  of  bone. 

A  contusion  of  the  scalp,  as  a  rule,  runs  a  course  without  accident  or 
complications.  The  swelling  appears  promptly  after  receipt  of  the 
injury,  especially  in  the  subcutaneous  variety.  The  pain,  which  at 
first  is  sharp  and  severe,  soon  subsides.  The  ecchymosis  does  not 
appear,  as  a  rule,  until  after  twenty-four  hours,  and  may  continue  to 
increase  for  another  twenty-four  hours,  rarely  longer.  The  area  is 
painful  to  pressure,  firm  in  the  subcutaneous  variety  but  may  have  a 
softened  central  portion  surrounded  by  a  firm,  dense  rim  in  the  sub- 
aponeurotic and  subperiosteal  varieties.  These  latter  usually  form 
more  slowly,  and  while  the  subcutaneous  variety  rapidly  disappears, 
in  twenty-four  to  forty-eight  hours,  the  latter  varieties  may  persist 
for  long  periods  and  may  require  special  treatment,  as  incision. and 
drainage,  to  bring  about  a  cure. 

A  special  form  of  subperiosteal  hematoma,  which  presents  some 
peculiarities  and  which  is  not  an  infrequent  result  of  instrumental 
delivery  during  a  difficult  labor,  is  the  cephalhematoma.  The  peri- 
osteum in  a  newborn  infant  is  comparatively  thick,  dense  and  firm, 
and  along  the  sutures  between  the  bones  it  is  intimately  adherent  to 
the  dura  mater.  In  these  cases  the  blood,  extravasated  beneath 
the  periosteum,  raises  it  away  from  the  bone,  usually  to  its  full  extent, 
but  does  not  extend  beyond  its  borders.  It  usually  takes  twenty-four 
hours  to  develop,  occurs  most  frequently  under  the  parietal  bone  and 
is  absorbed  very  slowly,  at  times  remaining  several  months  before  it 
entirely  disappears  and  then  oftentimes  leaves  a  ridge  of  thickened 
bone  about  its  periphery.  Scrupulous  care  should  be  taken  to  prevent 
infection  by  pathogenic  micro-organisms  as  this  is  extremely  serious 
and  may  end  fatally.     Absorption  usually  occurs  in  eight  to  ten  weeks. 

Any  one  of  these  varieties  may  become  infected  with  pathogenic 
micro-organisms,  which  is  especially  liable  to  occur  when,  in  addition 
to.  the  contusion,  there  is  also  an  abrasion  of  the  scalp.  This  must 
be  treated  as  a  cellulitis  or  abscess  of  scalp. 

Treatment. — The  application  of  ice-cold  compresses  usually  relieves 
the  pain  and  tends  to  diminish  the  swelling  in  the  subcutaneous 
contusions  or  hematomata.  A  moderated  amount  of  pressure  by 
a  dry  gauze  compress  and  bandage  will  control  somewhat  the  extrava- 
sation in  the  subperiosteal  and  subaponeurotic  varieties.  In  certain 
cases  where  absorption  is  particularly  slow,  one  can  draw  off  the  fluid 


328  INJURIES  AND  DISEASES  OF  HEAD  AND  BRAIN 

with  a  trochar  or  make  a  small  incision  at  the  most  dependent  portion. 
The  fluid  is  usually  dark  maroon  to  brown  in  color,  contains  fat 
droplets  and  crystals  of  hematoiden.  The  greatest  care  should  be 
exercised  to  maintain  asepsis  during  these  procedures,  and  pressure 
with  a  compress  and  bandage  should  be  applied  and  maintained  for 
three  or  four  days. 

Wounds. — These  may  be  classified,  as  are  wounds  elsewhere  in  the 
body,  into  incised,  punctured,  lacerated,  gunshot,  and  wounds  with 
loss  of  substance. 

Incised  wounds  are  made  by  sharp,  cutting  instruments  and  may 
involve  only  the  skin,  or  may  extend  deeper,  even  down  to  the  bone. 
They  may  be  caused  by  blunt  instruments  also,  owing  to  the  peculiar 
manner  of  attachment  of  the  tissues  to  the  bone.  The  blunt  instru- 
ment strikes  the  scalp  obliquely  and  moves  the  scalp  on  the  underlying 
bone  until  the  scalp  is  torn  in  a  sharp  line  at  the  periphery  of  the  area 
moved  and  usually  on  the  side  from  which  the  blow  is  struck. 

The  edges  of  an  incised  wound  are  clean  cut  and  bleed  freely  as 
the  vessel's  lumen  is  kept  open  on  account  of  their  walls  being  held 
apart  by  the  fibrous  trabecular  in  which  they  run.  The  wounds  which 
run  transversely  across  the  head,  dividing  the  aponeurosis,  gape  more 
than  those  running  in  the  opposite  direction,  as  the  contraction  of  the 
muscular  bellies  pulls  them  asunder. 

Punctured  wounds  are  caused  by  small,  sharp  instruments.  They 
usually  have  a  short  course  and  often  the  bone  is  injured,  also  the  point 
of  the  instrument  may  be  broken  off  in  the  bone.  At  times  the 
punctured  wound  has  a  long  tract  and  the  instrument  may  have  made 
a  wound  of  exit.  Unless  a  branch  of  some  large  artery  has  been  injured 
the  bleeding  is  slight. 

Lacerated  wounds  of  the  scalp  are  by  far  the  most  frequent  and  are 
characterized  by  having  a  bizarre,  oftentimes  stellate,  form;  the 
edges  are  ragged  and  irregular,  and,  because  they  are  usually  caused 
by  some  blunt  object,  the  areas  in  the  immediate  vicinity  are  contused 
and  show  abrasions.  Inasmuch  as  the  scalp  is  torn,  the  bleeding  is 
less  than  in  the  incised  variety,  except  where  a  large  arterial  branch  is 
injured. 

Treatment. — Incised,  punctured,  and  lacerated  wounds  of  the  scalp 
should  be  treated  with  intelligent  care  along  the  principles  of  antiseptic 
surgery,  and  because  the  wound  is  small  and  often  insignificant,  it 
should  not  be  neglected,  but  should  receive  as  much  attention  as  larger 
wounds  elsewhere.  The  area  about  the  wound  should  be  shaved  for 
about  one  inch,  a  piece  of  sterile  gauze  having  been  previously  packed 
into  the  wound  to  prevent  any  fresh  contamination.  The  scalp  should 
then  be  scrubbed  with  green  soap  and  water  with  a  scrubbing  brush. 
If  there  is  any  foreign  material  in  the  wound  it  should  be  removed. 
This  may  be  composed  of  hair,  street  dirt,  particles  of  clothing, 
and  should  all  be  removed.  The  wound  and  the  surrounding 
area   of   scalp  should   then  be  disinfected  with  half-strength    tine- 


INJURIES  OF  THE  SCALP  329 

ture  of  iodine.  This  is  a  most  painful  process.  All  bleeding  ves- 
sels which  show  a  change  of  rate  synchronous  with  the  heart  beat 
should  be  ligated.  This  may  be  at  times  a  difficult  task  and  may 
be  only,  or  best,  accomplished  by  sutures  which  also  tend  to  close  the 
wound.  The  edges  of  the  wound  should  be  approximated  as  accu- 
rately as  possible,  care  being  taken  not  to  turn  in  nor  invert  the  skin. 
The  suture  material  best  adapted  to  this  purpose  is  horsehair,  or  fine 
silkworm  gut.  Silk  may  be  used,  but  it  tends  more  to  subsequent 
infection.  As  a  rule,  scalp  wounds  should  not  be  drained,  unless  evi- 
dences of  cellulitis  and  infection  by  micro-organisms  are  present.  The 
fact  that  the  wound  is  not  clean,  but  contains  infective  material,  even 
microscopic  particles,  is  no  reason  for  drainage,  provided  the  wound 
is  seen  a  comparatively  short  time  after  the  injury.  The  scalp  is  so 
vascular  that  it  can  take  care  of  a  great  deal  of  infection,  and  the 
tissues  also  appear  to  possess  a  certain  heightened  immunity.  When 
one  of  the  deeper  structures  is  divided,  as  the  aponeurosis,  it  should 
be  coapted  with  catgut  sutures  as  accurately  as  possible.  It  may  be 
deemed  advisable  to  drain  certain  wounds  in  which  a  flap  of  tissue  has 
been  raised  up  or  there  has  been  considerable  undermining  of  the  deep 
attachments,  but  even  in  these  cases  healing  will  proceed  much  more 
smoothly  if  the  surgeon  expends  his  energies,  rendering  the  wound  as 
clean  as  possible  when  it  is  first  seen  and  cared  for,  than  if  he  trusts 
to  drainage  to  carry  off  the  infectious  material.  Scalp  wounds 
of  moderate  size  may  be  dressed  with  plain  sterile  gauze,  which  is  held 
in  place  by  collodion  or  adhesive  plaster.  Large  ones,  of  course,  will 
require  a  proper  bandage  to  retain  the  dressing  in  place.  Scalp  wounds 
heal  rapidly,  and  in  seven  days  even  the  largest  are  closed  and  stitches 
may  be  removed.  At  times  a  slight  infection  may  be  averted  by  an 
early  removal  of  the  stitches,  for  instance,  after  forty-eight  hours. 

Gunshot  wounds  of  the  scalp  uncomplicated  by  visceral  injury  are 
rare  and  do  not  offer  any  peculiarities  over  the  same  class  of  wounds 
elsewhere.  They  are  usually,  however,  complicated  by  wounds  of  the 
skull  or  its  contents  and  will  be  taken  up  more  fully  in  gunshot  wounds 
of  the  brain. 

Wounds  of  the  scalp  with  loss  of  substance  may  assume  serious  impor- 
tance in  direct  proportion  to  the  size  of  the  tissue  lost  or  the  area  of  the 
skull  left  exposed.  On  account  of  the  unyielding,  non-compressible  char- 
acter of  the  skull  it  may  become  impossible  to  cover  completely  the 
exposed  bone.  The  same  scrupulous  care  in  cleansing  the  wound  should 
be  taken  as  in  the  simple  scalp  wounds.  They  should  be  dressed  with  a 
bland  ointment  (10  per  cent,  boric  acid)  and  the  bone  left  to  granulate. 
Often  large  areas  of  .bone  denuded  of  periosteum  will  maintain  their 
nutrition  and  granulate,  when  they  may  be  grafted  or  covered  by 
means  of  a  plastic  operation.  In  the  cases  in  which  necrosis  follows 
only  the  outer  table  of  the  skull  exfoliates,  as  a  rule,  at  least  in  adults. 
In  children  and  infants  it  is  more  serious  as  the  dura  mater  may 
become  exposed  owing  to  the  death  of  the  skull  and  fatal  meningitis 


330         INJURIES  AND  DISEASES  OF  HEAD  AND  BRAIN 

ensue.  The  process  of  repair  is  a  tedious  one,  often  taking  several 
months  before  the  exfoliation  of  bone  is  complete  and  the  exposed  area 
covered  by  granulations. 

Avulsion. — Avulsion  of  the  scalp  is  an  unusual  injury,  and  consists 
of  a  tearing  off  of  the  scalp  from  the  skull.  It  occurs  most  frequently 
in  women  and  girls.  It  is  usually  the  result  of  having  the  long  hair 
caught  in  machinery  or  belting  and  wound  up  rapidly.  As  soon  as 
the  victim  feels  the  pull  she  quite  instinctively  throws  up  her  hands, 
clutches  each  side  of  her  head,  and  exerts  a  counter-pull.  The  line  of 
avulsion  varies  somewhat,  but  in  general  extends  from  the  region  of 
the  eyebrows  back  along  the  zygoma,  above  the  ear  and  down  the 
back,  following  about  the  line  of  growth  of  the  hair.  It  may  only 
remove  the  skin  and  subcutaneous  tissue,  but  usually  some  portion 
of  the  aponeurosis  and  even  the  periosteum  is  also  torn  off. 

The  patient  may  immediately  lose  consciousness,  or  she  may  retain 
consciousness  but  exhibit  evidences  of  profound  shock,  as  pallor, 
apathy,  superficial  respiration,  weak,  thready  pulse,  and  cold  sweat. 
The  hemorrhage  is  at  first  profuse  but  not  excessive,  the  vessels  from 
the  bone  being  the  last  to  thrombose.  Most  patients  recover  from 
the  shock,  the  bleeding  ceases  and  we  then  have  a  large  extensive 
raw  surface  with  no  skin  available  for  covering  it,  by  means  of  a 
plastic  operation. 

Treatment  and  Course. — The  loss  of  blood  may  be  alarming  from 
the  larger  arterial  trunks,  notably  the  temporal  and  occipital,  but 
in  many  cases  these  do  not  bleed,  as  the  inner  coat  curls  up,  and  the 
vessels  thrombose  due  to  the  tearing  violence  which  ruptures  them. 
When  these  vessels  bleed  they  must  be  ligated.  The  capillary  hemor- 
rhage can  best  be  controlled  with  gauze  compresses.  The  wound  is 
not  usually  very  septic,  but  it  should  be  thoroughly  cleansed  with  sterile 
water  and  saline  solution.  All  attempts  to  make  the  scalp  adhere 
have  failed  when  the  avulsion  has  been  complete.  The  wound  should 
be  dressed  with  boric  acid  ointment  or  gauze  soaked  in  alboline.  Wet 
dressings  give  a  sensation  of  cold  and  are  disagreeable.  The  periosteum 
soon  forms  granulations,  and  even  the  areas  of  bone  which  are  denuded 
of  periosteum  may  granulate  and  heal  without  necrosis.  Later  the 
wound  must  be  covered  with  Thiersch  grafts.  Infection  of  the  wound 
with  thrombosis  of  the  emissary  veins  and  consequent  meningitis  has 
occurred  and  been  the  cause  of  a  fatal  termination. 

Burns. — Burns  of  the  scalp  may  be  superficial  or  deep,  involve  large 
extensive  areas,  or  be  quite  circumscribed.  Blisters  do  not  form, 
as  the  serum  leaks  out  along  the  hairs  and  does  not  remain  confined 
beneath  the  epidermis.  Healing  is  slow  and  painful  and  the  edema 
which  occurs  is  much  more  extensive  than  in  burns  elsewhere.  In 
deep  burns  the  hair  follicles  are  destroyed  and  baldness  often  results. 
The  danger  of  infection  by  pyogenic  organisms  invariably  is  present 
and  may  prove  a  serious  complication.  Superficial  first-degree  burns 
or  scalds  may  be  left  untreated.     As  they  are  very  painful  the  adminis- 


DISEASES  OF  THE  SCALP  331 

tratioD  of  an  anodyne  may  be  necessary.  They  usually  heal  in  a  week 
to  ten  days.  The  deep  burns  are  best  treated  by  the  open  method, 
leaving  the  area  exposed  to  the  drying  action  of  the  air.  The  hair 
should  be  cut  close  over  the  burned  area,  if  it  has  not  already  been 
destroyed,  and  for  a  wide  area  about  the  burn.  Large  granulating 
areas  must  be  covered  by  skin-grafts.  Necrosis  of  the  skull  often 
follows  extensive  destruction  of  the  scalp  from  burns. 


DISEASES  OF  THE  SCALP. 

Cellulitis. — The  scalp  is  subject  to  the  same  pathological  processes 
as  are  other  portions  of  the  body,  but  these  are  modified  by  the  prox- 
imity of  the  skull  and  its  contents  both  in  respect  to  their  importance 
and  their  prognosis. 

All  accidental  wounds  of  the  scalp  are  infected  wounds.  In  the 
majority  of  cases  if  the  wound  is  carefully  cared  for  and  in  the  correct 
manner,  the  infection  is  taken  care  of  and  the  wound  heals  primarily. 
In  a  certain  number  of  cases,  however,  the  infection  increases  and  there 
results  one  of  the  many  forms  of  inflammation  of  the  scalp.  The  most 
frequent  is  cellulitis  about  the  immediate  vicinity  of  the  wound.  This 
is  evidenced  by  redness,  pain,  and  swelling  along  the  edges  of  the 
wound.  The  redness,  as  a  rule,  is  very  moderate,  which  is  true  of  all 
infections  of  the  scalp  where  redness  is  either  absent  or  very  slight. 
The  swelling,  on  the  other  hand,  is  well  marked,  is  a  soft  edema,  and 
extends  over  a  wide  area.  The  pain  is  not  excessive  and  is  rather  less 
in  degree  than  elsewhere  in  the  body.  The  presence  of  pus  in  the 
wound  is  often  not  readily  made  out,  as  fluctuation  is  not  easily 
demonstrated.  The  lymphatic  glands  of  the  group  into  which  the 
radicals  from  the  infected  area  drain,  become  tender,  swollen  and  firm. 

Treatment. — When  there  is  no  suppuration  the  removal  of  the 
stitches  from  the  wound  and  an  antiseptic  wet  dressing  of  bichloride 
of  mercury  (1  to  2000),  or  a  solution  of  aluminum  acetate,  often  results 
in  resolution  and  healing.  Whenever  pus  has  formed  it  is  best  to 
remove  all  the  sutures  and  separate  the  edges  of  the  wound  and  pack 
with  gauze  moistened  with  sterile  alboline.  This  will  keep  the  edges 
of  the  wound  apart  and  allow  free  drainage.  The  wound  should  be 
dressed  and  the  packing  removed  within  twelve  hours.  The  alboline 
prevents  adhesions  forming  between  the  edges  of  the  wound  and  the 
gauze,  so  that  no,  or  only  a  very  slight,  amount  of  hemorrhage  will 
result  from  removal  of  the  dressing. 

Furunculosis. — Furunculosis  of  the  scalp  requires  the  greatest  care 
in  cleansing  the  scalp.  The  hair  must  be  shaved  about  the  furuncle 
and  care  taken  that  the  discharges  from  the  opening  do  not  infect  other 
areas.  Treatment  should  aim  at  incision  of  the  furuncle,  drainage 
of  wound  and  disinfection  of  discharge  and  secretion  by  dressings  of 
bichloride  of  mercury  or  aluminum  acetate  (1  to  1000),  and  frequent 


332         INJURIES  AND  DISEASES  OF  HEAD  AND  BRAIN 

enough  changing  of  these,  so  that  they  shall  not  become  soaked  with 
the  wound  discharges. 

Abscess. — An  abscess  of  the  scalp  without  some  disease  of  the  bone 
of  the  skull  is  a  rare  affection.  It  may  arise  from  infection  commencing 
from  an  abrasion  or  from  a  hematoma.  The  symptoms  do  not  in  any 
way  differ  from  abscesses  elsewhere,  but  the  proximity  of  the  skull 
and  its  contents  gives  rise  to  possible  dangers  from  the  extension  of  the 
process  to  them.  Its  treatment  is  incision  and  drainage.  The  incision 
should  be  so  planned  as  to  avoid  as  much  as  possible  the  main  arterial 
trunks,  and  this  may  be  accomplished  best  if  they  are  made  radically 
from  the  vertex  or  bregma. 

Erysipelas. — Erysipelas  of  the  scalp  is  not  a  rare  form  of  the  disease 
and  it  differs  from  erysipelas  elsewhere  in  many  respects.  It  may 
originate  from  a  wound  of  the  scalp,  however  small  itself,  but  this  is 
unusual,  as  it  is  most  frequently  an  extension  from  a  focus  elsewhere 
and  generally  follows  erysipelas  of  the  face,  when  the  process  extends 
from  before  backward. 

Symptoms. — -The  anatomical  peculiarities  of  the  scalp  modify  in 
a  marked  degree  the  course  of  erysipelas.  One  will  seek  in  vain  for 
the  redness  of  St.  Anthony's  fire,  for  the  sharply  defined,  slowly 
advancing  border,  raised  above  the  surrounding  normal  areas,  and  for 
the  presence  of  bullae,  but  will  find  a  soft,  baggy  swelling,  diffuse  and 
not  well  demarcated,  and  excessively  tender  to  pressure  where  it  is 
advancing.  This  painful  characteristic  is  often  the  best  criterion  as 
to  the  advanced  limits  of  the  disease.  There  is  apt  to  be  delirium  of  a 
more  or  less  violent  nature,  and  there  may  be  stupor  or  even  coma. 
The  temperature  is  high  and  the  pulse  is  rapid.  The  patients  show 
signs  of  a  severe  illness  and  the  effects  of  an  acute,  profound  infection, 
with  dry  tongue,  loss  of  appetite,  nausea  and  vomiting. 

Though  delirium,  stupor  and  coma  frequently  accompany  an  attack 
of  erysipelas  of  the  scalp,  and  there  is  often  muscular  twitching, 
meningitis  is  a  rare  and  unusual  sequence,  and  when  it  does  occur  it 
is  due  either  to  suppuration  and  the  formation  of  a  diffuse  phlegmon, 
or  thrombosis  of  an  emissary  vein  and  so  an  extension  of  the  infection 
to  the  meninges. 

Course. — The  disease  usually  lasts  seven  to  nine  days,  but  may  be 
prolonged  over  a  much  more  extended  period.  As  it  progresses  it 
passes  from  before  backward  and  may  invade  the  trunk.  When  this 
occurs  it  passes  down  the  back  of  the  neck  and  extends  to  the  chest, 
arms,  and  back.  Even  should  the  first  focus  be  in  the  frontal  region 
it  rarely  extends  to  the  face.  The  hair  usually  falls  out  after  a  severe 
attack  but  it  will  return  after  six  months  to  a  year. 

Treatment. — Treatment  is  for  the  most  part  expectant  with  careful 
nursing.  Local  applications  of  boric  acid  in  saturated  solution,  ice-cold, 
frequently  changed,  will  aid  in  controlling  much  of  the  discomfort. 
Shaving  the  scalp  to  permit  the  application  of  ointments  is  not  good 
practice  as  there  is  no  local  application  which  is  universally  successful 
in  controlling  the  spread  of  the  disease. 


NEW  GROWTHS  OF  THE  SCALP  333 

NEW  GROWTHS  OF  THE  SCALP. 

Lipoma. — This  is  a  rare  tumor  constituting  about  2  per  cent,  of  all 
lipomata.  It  occurs  most  frequently  in  adults  of  advanced  years, 
but  cases  have  been  reported  in  which  the  new  growth  began  in  early 
life.  It  is  situated  most  frequently  in  the  frontal  region,  next  occipital, 
then  temporal  and  parietal. 

Pathology. — It  is  usually  situated  in  the  loose  areolar  connective  tissue 
beneath  the  aponeurosis  of  the  occipitofrontalis  muscle.  About  its 
periphery  the  periosteum  is  raised  into  a  firm,  dense,  thickened  ridge. 
As  a  rule,  there  is  no  depression  in  the  bone,  but  in  rare  instances  such 
has  been  observed.  The  lipoma  is  not  lobulated,  although  there  are 
numerous  fibrous  trabecule  running  through  it  which  bind  it  firmly 
to  the  periosteum. 

Symptoms. — Lipomata,  as  a  rule,  are  broad,  flat,  sessile  growth, 
like  half  of  a  flattened  sphere,  rarely  pedunculated.  They  are  not 
lobulated.  The  skin  over  them  is  unchanged  and  quite  normal. 
The  tumor  is  usually  soft,  almost  fluctuating,  and  rarely  elastic.  The 
skin  can  be  moved  over  it  and  raised  into  folds.  The  tumor  is 
smooth  and  does  not  move  to  any  great  extent  on  the  deeper  parts. 
It  is  not  painful.     The  growth  is  slow. 

Treatment. — Removal  of  growth  by  operation. 

Sebaceous  Cysts. — These  are  the  most  common  of  the  swellings 
of  the  scalp.  They  are  most  frequently  seen  in  women.  They  are 
rare  in  early  adult  life,  and  are  never  observed  before  fifteenth  year, 
being  most  often  observed  in  old  or  elderly  persons. 

Pathology. — They  develop  from  the  sebaceous  glands  along  the 
roots  of  the  hairs.  They  consist  of  a  quantity  of  sebaceous  material 
enclosed  in  an  epithelial  lined  cavity,  the  cells  of  which  are  derived 
from  the  cells  of  the  sebaceous  gland  from  which  the  cyst  developed. 
There  are  several  layers  of  epithelial  cells  in  the  wall.  The  duct 
generally  is  closed  in  the  cysts  in  the  scalp,  though  it  is  often  open  in 
those  found  elsewhere  in  the  body.  The  cysts  found  in  the  scalp  are 
always  disconnected  from  the  skin  lying  in  the  subcutaneous  tissue. 
They  are  never  beneath  the  aponeurosis  of  the  muscles. 

Symptoms. — They  cause  no  discomfort  and  only  their  appearance 
annoys.  When  small  they  are  round  but  as  they  increase  in  size  they 
often  become  flattened  as  the  scalp  presses  them  against  the  bone. 
They  have  been  described  as  pedunculated,  but  this  is  exceedingly 
rare.  When  several  are  situated  near  one  another  they  may  be 
separated  by  a  groove  only.  As  they  develop  the  skin  over  them 
becomes  thinned  and  the  hair  atrophies  and  drops  out  leaving  a  bald 
area.  This  often  appears  paler  than  the  surrounding  scalp.  At  times 
a  comedo  may  be  made  Out  on  the  summit.  They  vary  in  size  from 
0.5  cm.  to  10  to  15  cm.  in  diameter. 

On  palpation  the  small  cysts  are  hard  and  shotty,  while  the  large 
ones  are  doughy,  soft,  elastic  and  when  infected,  fluctuating.     Their 


334  INJURIES  AND  DISEASES  OF  HEAD  AND  BRAIN 

consistency  is  uniform.  The  skin  does  not  move  readily  over  the  small 
ones,  but  may  over  the  large  ones.     They  move  on  the  deeper  parts. 

They  rarely  disappear  spontaneously,  but  may  rupture,  discharge 
their  contents,  and  form  fistula?  which  close  and  the  secretion  reaccumu- 
lates  and  again  discharges.  They  may  become  infected,  when  the 
contents  become  fluid  and  discharge,  by  involvement  of  the  skin  with 
resultant  thinning  and  necrosis.  The  sac  often  sloughs  out  when  a 
permanent  cure  results.  At  times  they  undergo  calcareous  degenera- 
tion when  hard  plates  may  be  felt  in  the  walls.  In  some  instances  a 
malignant  change  has  occurred  in  them. 

Treatment. — The  removal  of  the  wall  of  the  cyst  is  necessary  to 
insure  a  permanent  cure,  for  if  a  small  portion  remains  it  will  develop 
a  new  cyst.  They  may  be  readily  removed  under  local  anesthesia 
(0.5  per  cent,  novocaine  solution). 

Dermoid  Cysts. — These  are  rare  on  the  scalp.  They  appear  usually 
in  the  first  two  to  three  years  of  life,  but  may  be  noted  earlier ;  at  the 
latest  about  puberty.  They  probably  have  been  present  at  birth  but 
have  not  been  noticed  until  a  later  date. 

Pathology. — They  are  the  result  of  an  inclusion  of  the  ectoderm  about 
the  ninth  to  fifteenth  day.  The  wall  is  composed  of  all  the  elements 
of  the  skin,  with  its  appendages,  hair,  sebaceous  and  sweat  glands. 
The  contents  vary  somewhat;  oftentimes  sebaceous  material,  at  times 
brownish,  due  to  hemorrhages  into  the  sac;  it  may  be  oily  or  even 
serous.  In  the  latter  case  it  may  simulate  a  cephalocele,  especially 
if  the  skull  beneath  it  is  defective.  They  are  situated  beneath  the 
aponeurosis  and  may  have  an  attachment  with  the  dura. 

Symptoms. — Dermoid  cysts  give  no  discomfort.  The  skin  is 
unchanged  over  them.  They  are  usually  single  and  occur  most  often 
in  certain  situations — at  the  outer  end  of  the  supra-orbital  ridge  or 
adjoining  temporal  region,  inner  angle  of  eye,  glabella  and  root  of 
nose,  over  the  site  of  the  large  and  small  fontanelle  and  in  the  parietal 
occipital  suture  and  mastoid  region.  Certain  of  them  occur  in  the 
orbit  when  they  communicate  by  a  prolongation  with  a  process  in  the 
temporal  fossa.  They  have  an  elastic  or  doughy  consistency.  The 
skin  moves  readily  over  them  and  they  do  not  move  on  the  deeper 
parts.     They  are  of  slow  growth. 

Treatment. — Complete  removal  under  local  anesthesia  (0.5  per  cent, 
novocaine  solution)  is  the  proper  procedure  in  the  superficial  varieties; 
in  those  connected  with  the  dura,  general  anesthesia  may  be  necessary. 

ANATOMY  OF  THE  SKULL. 

The  skull  is  divided  into  face  and  cranium  or  cranial  cavity,  which 
is  again  divided  into  vertex  and  base.  The  vertex  is  composed  of  thin, 
flat  bones,  having  an  outer  and  an  inner  layer  of  compact  bone,  the 
inner  and  outer  tables  of  the  skull,  between  which  is  a  layer  of  cancellous 
bone,  the  diploe.     The  base  is  more  irregular  and  contains  many 


ANATOMY  OF   THE  SKULL  335 

cavities,  and  is  perforated  by  foramina  so  that  it  is  of  varying  thickness 
and  strength.  Lines  of  fracture  through  the  base  are  influenced 
greatly  in  their  course  and  direction  by  these  masses  of  varying  thick- 
ness and  by  the  foramina. 

The  cranial  cavity  is  lined  by  a  firm,  dense  membrane,  the  dura 
mater,  which  is  firmly  adherent  to  the  bone  and  serves  as  its  inner 
periosteum.  It  also  separates  different  portions  of  the  brain  from  one 
another  by  sending  processes  in  between  them,  and  it  supports  venous 
channels  between  its  layers,  by  which  the  blood  is  conveyed  from  the 
veins  of  the  brain  and  skull  to  the  veins  of  the  neck.  The  arterial 
supply  to  the  skull  also  runs  in  the  dura  mater.  It  is  lined  internally 
by  a  layer  of  pavement-endothelium.  The  sinuses  of  the  dura  mater 
are  lined  by  endothelium  and  receive  blood  from  the  dura  mater,  brain 
and  skull.  Their  walls,  composed  of  dura  mater,  are  firm,  and  do  not 
collapse  when  empty  of  blood.  They  contain  no  valves.  They  all 
run  toward  the  jugular  foramen  and,  with  few  exceptions,  empty  their 
contained  blood  into  the  jugular  veins.  They  communicate,  however, 
with  the  general  circulation  at  other  points,  namely,  through  the 
ophthalmic  vein,  vertebral  plexus  and  various  emissary  veins,  as  the 
mastoid  and  parietal.  On  either  side  of  the  superior  longitudinal  sinus 
we  have  more  or  less  extensive  spaces  filled  with  blood,  the  parasinoidal 
sinuses  or  lateral  lacuna?.  These  are  extensions  laterally  of  the  lumen 
of  the  sinus.  The  Pacchionian  bodies  project  into  them  as  do  various 
processes  of  the  pia  mater. 

The  pia  arachnoid  covers  the  outer  surface  of  the  brain  and  cord  and 
fills  in  the  space  between  the  brain  and  dura  mater.  Formerly  these 
were  considered  as  two  separate  structures,  but  it  is  much  better  and 
more  correct  to  consider  them  as  one  structure  composed  of  two  more 
or  less  well  differentiated  portions,  which  differ  somewhat  in  their 
histological  appearance  and  character.  The  pia  mater  lies  closely 
applied  to  the  outer  surface  of  the  brain  and  sends  processes  in  between 
the  convolutions.  The  bloodvessels  of  the  brain  are  supported  by 
the  pia,  which  is  a  firm,  fibrous  coating,  the  fibres  of  which  are  continu- 
ous with  those  of  the  arachnoid.  This,  on  the  other  hand,  is  a  wide 
meshed  network  of  fibres  which  divide  the  space  between  dura  mater 
and  pia  mater  into  many  compartments  of  varying  size  which  are 
filled  during  life  with  a  colorless  fluid,  the  cerebrospinal  fluid.  The 
cerebrospinal  fluid  is  secreted  by  the  cells  of  the  choroid  plexus, 
flows  through  a  slit  in  the  descending  horn  and  through  the  foramen 
of  Magendie  into  the  cisterna  magna.  In  health  it  has  the  following 
characteristics:  there  is  about  60  to  150  c.c,  and  only  from  20  to  30 
c.c.  of  this  is  in  the  ventricles  of  the  brain,  the  remainder  being  in  the 
subarachnoid  space.  It  is  a  clear  and  limpid  fluid,  colorless,  faintly 
alkaline,  sp.  gr.  1.000  to  1.003;  contains  a  faint  trace  of  albumin, 
0.2  to  0.5  per  cent.;  gives  no  distinct  nucleo-albumin  reaction:  at  times 
it  contains  a  substance,  which  reduces  Fehling's  solution,  either  glucose 
or  pyrocatechin;  it  also  contains  chalin  cholesterin.     The  potassium 


336  INJURIES  AND  DISEASES  OF  HEAD  AND  BRAIN 

content  is  greater  than  that  of  sodium.  Normally  it  is  under  a 
pressure  of  60  to  100  mm.  of  water;  in  disease  this  may  be  greatly 
increased,  even  as  high  as  200  to  800  mm.  of  water.  It  normally 
contains  a  few  cells,  while  in  pathological  conditions  this  number 
may  be  greatly  increased.  The  cerebrospinal  fluid  is  absorbed  mainly 
by  the  veins,  especially  the  processes  of  the  pia  arachnoid  which  pro- 
jects into  the  parasinoidal  sinuses.  It  is  absorbed,  but  very  slightly,  by 
the  lymphatic  vessels  of  the  nose,  the  sheaths  of  the  nerves,  notably 
the  optic  and  the  perilymphatic  space  of  the  labyrinth  of  the  ear. 

The  circulation  of  the  brain  is  derived  from  arteries  which  run  in 
the  pia  mater.  They  form  a  rich  network  over  the  cortex  of  the  brain, 
and  are  true  end-arteries  in  the  cerebral  substance.  The  veins  have 
four  times  the  capacity  of  the  arteries.  They  have  thin  walls,  are 
without  valves  and  many  of  them  lack  a  muscular  coat.  The  blood 
is  brought  to  the  brain  under  high  pressure  and  the  return  flow  is 
free  and  unimpeded  in  the  veins  where  the  pressure  is  low. 

INJURIES  OF  THE  SKULL. 

Fractures  of  Skull. — Their  main  importance  is  due  to  possibilities 
of  what  in  other  fractures  would  be  termed  complications  or  accom- 
panying lesions,  namely,  those  to  the  neighboring  soft  parts.  Fractures 
of  the  skull  differ  from  fractures  elsewhere  in  that  the  function  for  which 
the  skull  is  intended,  namely,  the  containing  and  protecting  of  the 
brain,  may  be  seriously  interfered  with  by  the  fracture;  therefore  vis- 
ceral injury,  or  injury  to  vessels  and  nerves  with  their  consequences 
are  much  more  dangerous  than  elsewhere. 

Classification. — Fractures  of  the  skull  are  divided  into  those  involving 
the  vault,  those  of  the  vault  radiating  to  base,  and  those  of  the  base: 
also  those  without  brain  injury  and  those  associated  with  brain  injury. 

Frequency. — According  to  different  statistics  these  range  from  1.45 
per  cent,  to  3.8  per  cent,  of  all  fractures. 

Causation. — Outer  Table  Alone.  These  are  caused  by  sharp  instru- 
ments, or  a  glancing  blow,  and  may  divide  the  outer  table  only.  They 
are  rare. 

Inner  Table  Alone. — A  blunt  instrument  may  bend  the  skull,  and 
the  inner  table  being  on  the  concave  side  of  the  arch,  undergoes  a 
separating  force,  while  the  outer  table  undergoes  a  compressing  force, 
and  in  consequence  small  fragments  may  be  driven  off  from  the  inner 
table,  leaving  the  outer  table  uninjured.     This  also  is  rare  (Fig.  168). 

Circumscribed  without  Displacement. — A  small,  blunt  instrument,  as 
a  hammer  or  stone,  or  other  missile,  strikes  the  skull  with  sufficient 
violence  to  cause  a  fracture  about  the  periphery  of  the  area  of  contact 
of  the  vulnerating  body,  but  the  force  is  arrested  and  spends  itself  in 
causing  the  fracture,  and  in  consequence,  the  fragment  of  bone  remains 
in  place.  This  also  may  result  from  falls  on  the  head,  especially  on 
the  frontal'  eminences. 


INJURIES  OF  THE  SKULL 


337 


Circumscribed  with  Displacement. — This  occurs  when  the  force 
driving  the  vulnerating  body  continues  to  act  after  the  skull  is  fractured 
and  the  fractured  portion  is  driven  inward  and  becomes  caught 
beneath  the  edge  of  surrounding  bone,  and  remains  in  this  new  abnor- 
mal position,  held  fast  by  the  pressure  of  the  cranial  contents.  These 
last  two  forms  are  often  comminuted  and  there  coexist  radiating  lines 
of  fracture  extending  into  the  surrounding  skull  (Fig.  169). 

Bursting  Fractures. — These  are  caused  by  a  violence  acting  over  a 
wide  area  of  the  skull  and  give  rise  to  a  shortening  of  the  diameter 
of  the  skull  in  the  direction  of  the  force's  action.  There  results  from 
this  a  widening  of  the  skull  in  a  direction  at  right  angles  to  the  direction 
of  the  force,  and  this  gives  rise  to  fractures  parallel  to  the  direction 
of  force.     They  may  be  of  the  base  or  the  vault,  or  involve  both. 

Bending  Fractures. — At  times  the  force  acting  over  a  wide  area  of 
the  skull  causes  a  fracture  at  the  edge  of  the  area  on  which  the  force 


Fig.  168. — Mechanism  of  fracture        Fig.  169. — Circumscribed  depressed  fracture, 
of  the  internal   table   by   bending  of  (Konig.) 

the  bone. 

acts  and  the  line  of  fracture  is  then  at  right  angles  to  the  direction  of 
the  line  of  force.  These  may  be  through  the  base,  but  usually  involve 
both  the  vault  and  the  base,  or  the  vault, alone. 

The  line  of  fracture  may  be  in  any  direction,  but  there  are  certain 
lines  which  the  fracture  commonly  follows.  These  lines  are  probably 
largely  determined  by  the  presence  of  foramina  and  the  thickened 
portions  occupying  the  base  of  the  skull.  They  are  as  follows: 
.  1.  Line  commences  anteriorly  at  ethmoid  plate  near  the  crista  galli, 
or  laterally  from  it,  then  passes  through  the  orbital  plate  of  the  frontal 
bone  to  the  optic  foramen  in  the  lesser  wing  of  the  sphenoid;  thence  to 
foramina  rotundum  and  ovale  in  the  greater  wing  of  the  sphenoid; 
and  then  either  (a)  laterally  toward  the  squamous  portions  of  tem- 
poral bones,  or  (b)  posteriorly  through  the  middle  lacerated  foramen 
and  jugular  foramen  on  anterior  and  posterior  border  of  the  apex 
of  the  pyramidal  process  of  the  temporal  bone  to  the  foramen  magnum, 
and  posterior  through  the  thinner  portion  of  the  occipital  bone. 
22 


338 


INJURIES  AND  DISEASES  OF  HEAD  AND  BRAIN 


2.  Line  passes  transversely  or  obliquely  through  the  sella  turcica 
in  the  thin  roof  of  the  sphenoid  sinus  from  the  foramen  rotundum  of 
one  side  to  the  middle  lacerated  foramen  of  the  opposite  side. 

3.  Line  passes  through  the  occipital  bone  and  the  pyramidal  process 
of  the  temporal  bone  between  the  hypoglossal  canal,  jugular  foramen, 
acoustic  foramen  and  foramen  spinosum. 

4.  Line  of  fracture  extends  about  foramen  magnum  "ring  fracture," 
following  a  fall  on  the  feet  or  buttocks  or  on  top  of  the  head,  where  the 
spinal  column  acting  through  condyles,  punches  out  a  ring  of  bone 
about  the  foramen  magnum. 

5.  The  posterior  clinoid  processes  by  a  pull  on  the  tentorium  when 
the  anteroposterior  diameter  is  lengthened,  may  be  torn  loose.  (See 
Figs.  170  to  174.) 


Fig.  170. 


-Bursting  fracture  of  the  base. 
(Von  Bergmann.) 


Fig. 


171. — Circular  fracture  of  the  base. 
(Von  Bergmann.) 


Symptoms. — The  symptoms  referable  to  the  fractured  cranial  bones 
are  often  not  prominent  and  may  be  absent  altogether.  The  diagnosis 
is  often  established  by  a  history  of  trauma,  and  the  presence  of  injuries 
to  the  neighboring  soft  parts.  The  pain  is  moderate,  and  often  it  is 
only  a  headache  of  which  these  patients  complain.  In  circumscribed 
fractures  of  the  vault  with  displacement  of  the  fragments  the  deformity 
may  be  readily  palpated,  the  various  other  forms  give  no  such  data. 
The  basal  fractures  are  not  infrequently  accompanied  by  hemorrhage 
from  nose,  mouth  or  ear.  Hemorrhage  from  the  nose  is  not,  however,  a 
symptom  on  which  much  diagnostic  reliance  can  be  placed  because  it  is 
such  a  frequent  occurrence  in  so  many  injuries  which  are  trivial  in 
character.  Hemorrhage  from  the  mouth  also  is  not  a  very  reliable 
sign,  on  account  of  the  many  chances  there  are  by  which  the  bleeding 
may  arise  from  biting  the  tongue  or  other  minor  injury;  but  it  is  a 


INJURIES  OF  THE  SKULL 


339 


frequent  symptom  in  fractures  through  the  posterior  fossa  involving 
the  body  of  the  sphenoid  or  occipital  bones,  resulting  in  a  tearing  of  the 


Fig.  172. — Longitudinal  fracture  of  the 
base.     (Von  Bergmann.) 


Fig.  173. — Fracture  of  base,  from  fall 
from  scaffolding.  Hemorrhage  from  right 
ear  and  nose.  Death  from  meningitis. 
(Von  Bergmann.) 


posterior  vault  of  the  pharynx.     Hemorrhage  from  the  ear,  on  the 
other  hand,  is  of  very  much  greater  diagnostic  value,  because  it  always 


Fig.   174. — Bursting  fracture.     Patient  slipped,  striking  head  on  stone.     Direction  of 
force  indicated  by  arrow.     (Von  Bergmann.) 

implies  a  severe  traumatism  and  it  is  easier  to  rule  out  possible  sources 
of  origin  other  than  that  from  fracture.     These  possible  sources  which 


340  INJURIES  AND  DISEASES  OF  HEAD  AND  BRAIN 

might  lead  to  an  error  are  injuries  to  external  auditory  cana],  rupture 
of  drum  membrane,  fracture  of  tympanic  plate  and  rupture  of  mem- 
brana  tympani.  At  times  this  membrana  tympani  remains  intact 
and  there  occurs  an  accumulation  of  blood  behind  it  which  on  otoscopic 
examination  gives  rise  to  a  dark  bluish  appearance  to  the  drum. 
In  addition  to  the  hemorrhage  from  the  ear,  or  independent  of  it,  there 
may  be  an  escape  of  a  thin,  watery  discharge.  It  is  highly  important 
to  discover  the  exact  nature  of  this  discharge.  It  may  be  the  cere- 
brospinal fluid,  which  is  pathognomonic  of  fractured  skull.  The  flow 
is  abundant  and  prolonged,  at  first  mixed  with  blood,  later  quite  clear, 
comparatively  rich  in  chlorides  and  containing  a  small  amount  of 
albumin.  It  may  be  lymph  from  the  vessels  communicating  with  the 
inner  ear.  The  amount  may  be  large,  the  fluid  will  have  a  high 
albumin  content  and  contain  no  chlorides.  The  clear  discharge  may 
be  due  to  inflammation  of  the  middle  ear,  abundant  at  first,  and 
containing  a  large  amount  of  albumin,  while  later  becoming  scanty  and 
purulent.  The  extravasation  of  blood  with  formation  of  a  clot  may 
give  rise  to  a  discharge  of  serum.  This  will  appear  late,  some  days 
after  injury,  be  pinkish  in  color  and  contain  a  large  percentage  of 
albumin.  The  .r-ray  examination  often  will  reveal  the  presence  of  a 
figure  or  fracture  of  the  skull. 

Treatment. — Treatment  of  fracture  of  the  skull  is  for  the  most  part 
expectant.  Rest  in  bed  with  an  ice-cap  for  the  severe  headache,  and 
morphine  or  codeine  as  sedatives.  The  lesions  to  the  soft  parts,  brain, 
nerves,  and  bloodvessels  must  be  treated  quite  independently  of  the 
fractured  skull.  It  is  advisable  to  have  a  very  careful  watch  kept  over 
a  patient  in  whom  a  fracture  of  the  skull  is  suspected;  have  his  pulse 
counted  at  frequent  intervals;  also  his  blood-pressure  should  be  taken 
often.  A  patient  in  whom  a  fracture  of  the  skull  has  occurred  should 
be  kept  in  bed  for  a  week  after  the  disappearance  of  all  symptoms 
directly  due  to  the  fractures,  and  then,  if  no  complications  are  present, 
be  allowed  to  move  about  gradually. 

In  cases  of  circumscribed  fracture  with  displacement,  a  formal 
operation  should  be  undertaken,  and  the  displaced  fragments  either 
removed  or  replaced  in  their  normal  position.  In  all  these  injuries 
one  should  examine  carefully  the  inner  side  of  the  displaced  fragment 
for  detached  fragments  or  splinters  of  bone,  which  if  left  may  give  rise 
to  severe  late  complications,  pressure,  epilepsy,  etc. 

In  basal  fractures  with  symptoms  of  increasing  pressure,  which 
develop  gradually,  a  subtemporal  decompressive  operation  should  be 
performed.  In  these  cases  where  the  pressure  symptoms  supervene 
immediately  after  the  receipt  of  the  injury  and  develop  with  exceed- 
ing rapidity  probably  no  operative  measure  will  prove  efficient  to  save 
life.  The  mortality  is  high  and  the  results  of  interference  are  not 
brilliant,  but  operation  holds  out  the  only  chance  and  it  is  the  opinion 
now  that  except  in  moribund  cases,  decompression  gives  the  best 
prognosis. 


DISEASES  OF  THE  SKULL  341 

DISEASES  OF  THE  SKULL. 

Osteomyelitis.  Osteomyelitis  of  the  crania]  bones  is  a  rare  affec- 
tion. It  may  be  acute  <>r  chronic.  Of  the  acute,  dependent  on  its 
mode  of  origin,  we  distinguish  several  varieties,  as  spontaneous, 
traumatic  and  secondary. 

An  acute,  spontaneous  osteomyelitis  may  develop  without  any  local 
cause  being  discernible,  similar  to  the  osteomyelitis  of  the  long  hone- 
in  children.     It  is  a  rare  affection,  almost  exclusively  in  young  people. 

Etiology.-  Any  and  all  wounds  of  the  body  which  can  serve  as  a 
point  of  entrance  to  the  organism,  acute,  infectious  diseases  in  the 
period  of  their  convalescence,  and  any  debilitating  condition  which 
lowers  the  child's  resistance,  may  be  etiological  factors.  Traumatism 
which  does  not  break  the  skin  will  often  determine  the  site  of  the  lesion. 

At  one  time  Staphylococcus  aureus  was  thought  to  be  the  specific 
organism  of  all  osteomyelitis,  but  now  this  is  known  to  be  incorrect, 
and  we  may  have  Staphylococcus  albus  or  citreus,  pneumococcus, 
streptococcus,  typhoid  bacillus  and  certain  anaerobic  bacteria. 

Pathology. — The  infection  is  brought  to  the  site  of  the  disease  by 
the  blood  current  and  lodges  in  the  bone.  The  lesions  do  not  in  any 
way  differ  from  those  of  osteomyelitis  elsewhere  as  in  the  long  bones; 
intense  congestion  of  all  the  constituent  parts  of  the  bone,  hyperemia 
of  the  periosteum  with  the  formation  of  hemorrhagic  foci,  subperiosteal 
edema,  hyperemia  and  congestion  of  the  diploe.  These  lead  rapidly 
to  suppuration,  small  foci  of  pus  colleet  beneath  the  periosteum 
and  in  the  diploe.  The  bone  may  rapidly  lose  its  vitality,  areas  of 
necrosis  are  found  which  at  first  are  white,  then  change  to  black  and 
have  a  foul  odor.  The  sequestra,  however,  are  formed  only  after  a 
considerable  time  and  not  in  the  early  stages. 

The  sites,  in  order  of  frequence,  are  the  frontal,  parietal,  and  temporal 
bones,  and  vary  rarely  the  base  of  the  skull. 

Symptoms. — Onset  is  sudden  with  high  temperature,  104°  or  105°, 
often  accompanied  by  chills.  There  is  headache  of  an  intense  lancinat- 
ing character,  often  throbbing  which  is  worse  at  night,  and  not  relieved 
by  treatment — at  time-,  it  i-  frontal,  occipital  or  general.  There  is 
great  thirst. 

The  patient  looks  profoundly  ill  and  prostrated.  Often  there  is 
epistaxis  which  recurs  and  is  repeated  many  times,  and  there  may  be 
convulsions.  The  tongue  is  dry  and  coated.  There  may  be  marked 
tenderness  over  the  site  of  infection  on  the  head.  The  pulse  is  rapid. 
weak  and  soft.     There  is  often  alternating  diarrhea  and  constipation. 

The  course  of  the  disease  i-  very  rapid;  the  patient  is  acutely  ill, 
with  stupor,  delirium  and  a  typhoid  state  ending  in  coma  and  death. 

Many  of  the  symptoms  are  masked  by  seme  of  the  complications  due 
to  the  involvement  of  neighboring  structures,  when  the  picture  will 
be  that  due  to  involvement  of  those  structures,  meningitis,  throm- 
bophlebitis, sinusitis,  abscess  of  neck;  or  there  may  be  distant  lesions, 


342  INJURIES  AND  DISEASES  OF  HEAD  AND  BRAIN 

as  endocarditis,  pneumonia,  empyema,  and  any  of  these  may  mask 
the  picture  of  osteomyelitis  and  lead  to  an  erroneous  diagnosis.  The 
local  manifestations  may  not  become  evident  for  many  days  and  the 
general  complications  may  give  the  picture  to  the  disease. 

Treatment. — This  must  be  radical  and  prompt,  and  consists  in 
removing  the  diseased  bone,  exposing  the  dura  and  providing  ample 
and  efficient  drainage. 

Traumatic  Osteomyelitis. — The  traumatic  type  is  an  acute  osteo- 
myelitis which  follows  injury  associated  with  an  infected  wound. 
Adults  are  most  often  affected.  The  trauma  may  or  may  not  cause 
a  break  in  the  skin,  but  wounds  which  expose  the  skull  are  the  ones 
which  most  often  are  followed  by  infection  of  the  bones. 

The  infection  may  be  by  any  of  the  pyogenic  organisms. 

Pathology. — There  is  usually  a  superficial  involvement  of  bone, 
rarely  the  entire  thickness  of  the  skull,  but  simply  an  exfoliation  of  the 
outer  table.  But  when  large  areas  of  bone  have  been  denuded  the 
sequestra  are  correspondingly  large  and  irregular  in  shape. 

Symptoms. — The  onset  is  gradual  and  often  not  associated  with  any 
general  disturbance,  but  at  times  there  is  a  distinct  febrile  movement 
as  the  sign  of  a  bone  involvement.  Pain  is  not  such  a  prominent 
symptom  as  in  the  previous  variety,  but  still  it  is  often  present  and  apt 
to  be  worse  at  night ;  it  is  not  necessarily  localized  to  the  area  of  infected 
bone  but  may  be  generalized. 

Bare  bone  is  often  seen  but  it  is  impossible  to  state  by  inspection 
whether  there  is  an  osteomyelitis  or  not.  The  bone  may  be  felt, 
but  bare  bone  is  not  necessarily  dead  bone,  or  even  infected  bone. 

The  course  of  the  affection  may  indicate  whether  in  any  given 
infected  wound  there  had  occurred  an  osteomyelitis.  A  persistent 
sinus  discharging  pus  leading  down  to  bare  bone,  the  presence  of  a 
sequestrum,  persistent  fever  with  headaches,  pain  and  tenderness  in 
region  of  wound,  would  lead  to  the  diagnosis  of  osteomyelitis. 

Treatment. — This  should  be  guided  largely  by  the  course  of  the  dis- 
ease and  the  amount  of  fever.  If  there  is  high  fever  and  an  extensive 
infection,  a  radical  removal  of  bone  would  be  indicated,  but  as  a  rule 
conservative  treatment  is  the  best  procedure. 

Chronic  Osteomyelitis. — Chronic  osteomyelitis  is  a  much  more 
common  affection.  It  may  be  caused  by  middle-ear  disease,  acute 
osteomyelitis  resulting  in  the  formation  of  a  sequestrum,  or  necrosis. 

Pathology. — A  chronic  suppurative  process  resulting  in  death  of  bone 
with  or  without  sequestra,  caries  and  slow  bone  absorption.  Pus  may 
form  between  the  bone  and  dura  and  give  rise  to  an  extradural 
abscess  with  symptoms  of  cerebral  compression. 

Symptoms. — Chronic  osteomyelitis  gives  rise  to  the  long-persisting 
sinuses  which  discharge  pus  in  variable  quantities.  When  the  dis- 
charge is  slight  in  amount  the  sinus  may  crust  over  and  appear  to 
heal  up,  only  to  break  open  again  with  pain  and  a  discharge  of  increased 
amount  of  secretion.     This  may  persist  for  years,  notably  the  chronic 


DISEASES  OF  THE  SKULL  343 

disease  in  the  middle  ear.  From  time  to  time  and  often  without 
discernible  cause  the  process  will  light  up  and  give  symptoms  of  an 
acute  osteomyelitis  with  chills,  rigor,  fever,  headache,  malaise,  nausea, 
and  vomiting.  This  corresponds  usually  to  a  fresh  extension  of  the 
process,  or  to  accumulation  of  pus  under  tension.  Chronic  disease 
of  the  bones  of  the  skull  is  one  of  the  frequent  causes  of  brain 
abscess. 

Treatment. — Treatment  must  be  carefully  carried  out,  and  great 
care  taken  not  to  convert  the  chronic  process  into  a  virulent  active, 
acute  one.  Operative  interference  must  be  designed  to  remove  the 
dead  bone  and  at  the  same  time  to  provide  for  adequate  drainage 
after  its  removal.  Simple  curetting  of  an  old  sinus  is  a  dangerous 
practice  and  if  it  is  desired  to  clean  up  such  a  focus  a  free  exposure 
of  the  field  should  be  carried  out  by  a  formal  operation. 

Tuberculosis. — Tuberculosis  is  a  rare  disease  of  the  cranial  bones 
and,  although  it  does  occur  at  any  age,  it  is  more  frequent  in  children. 
It  is  usually  secondary  to  a  focus  elsewhere  in  the  body  but  may  be 
primary,  and  in  that  case  not  infrequently  follows  an  injury. 

Pathology. — The  process  starts  in  the  bone  and  extends  only  second- 
arily to  the  soft  parts.  It  frequently  forms  sequestra  and  perforates 
through  the  entire  thickness  of  the  bone,  and  the  inner  table  is 
involved  to  a  greater  extent  than  the  outer.  The  cavity  in  which 
the  sequestrum  lies  is  lined  by  tuberculous  granulation  tissue. 
There  may  be  several  such  foci.  Koenig  has  described  a  diffuse 
infiltration  of  the  skull  by  tuberculosis  without  sequestrum  formation. 
It  is  very  rare. 

Symptoms. — The  disease  often,  though  not  always,  commences  with 
pain  in  the  head,  severe  in  character  and  much  worse  at  night.  There 
is  pain  on  pressure  over  the  limited  area  involved  in  the  process,  and 
soon  after  the  onset  there  appears  a  swelling.  This  is  at  first  tender 
and  firm,  but  sooner  or  later  may  soften  and  fluctuate,  especially  in 
the  centre.  This  may  pulsate  and  it  may  be  reducible  on  pressure. 
After  a  variable  length  of  time  the  overlying  skin  becomes  thinned 
and  ulcerates  with  a  discharge  of  characteristic  tuberculous  pus. 
There  is  then  established  a  tuberculous  ulcer  or  a  sinus  lined  with 
tuberculous  tissue  and  leading  down  to  bare  diseased  bone,  often  a 
sequestrum.  This  may  persist  for  a  long  time,  as  the  disease  runs  a 
very  slow  course. 

Treatment. — Treatment  should  consist  in  the  complete  removal  by 
operation  of  all  the  tuberculous  tissue,  and  the  healing  must  take 
place  by  second  intention. 

Syphilis. — Syphilis  of  the  cranial  bones  is  not  a  common  manifesta- 
tion of  the  disease.  It  may  follow  the  hereditary  or  acquired  form. 
During  the  secondary  stage  the  skull  is  a  frequent  site  for  the  very 
painful  circumscribed  swellings  of  the  periosteum  which  do  not  break 
down  and  readily  yield  to  antisyphilitic  treatment.  During  the  tertiary 
stage  there  develop  the  gummatous  processes  which  cause  profound 


344  INJURIES  AND  DISEASES  OF  HEAD  AND  BRAIN 

changes  in  the  bone,  resulting  according  to  Dieulafoy,  in  two  types, 
the  perforating  and  the  hypertrophic. 
Pathology. — The  perforating  form  is  not  an  unusual  manifestation  and 

is  due  to  a  deposit  of  gummatous  tissue  in  the  periosteum  or  dura  mater, 
and  results  in  an  absorption  of  the  bone  due  to  a  rarefying  osteitis. 
A  perforation  of  the  cranium  may  occur.  Side  by  side  with  this 
process  and  in  a  portion  of  the  bone  immediately  next  there  may 
occur  a  growth  of  new  bone  which  is  denser  than  normal. 

The  hypertrophic  form  results  in  the  production  of  new  bone 
over  circumscribed  areas.  These  areas  may  coalesce  and  give  the 
appearance  of  a  diffuse  thickening. 

Symptoms.— Symptoms  will  differ,  according  to  Dieulafoy,  whether 
the  process  is  on  the  external  or  internal  surface  of  the  skull.  The 
pain  in  the  head,  worse  at  night,  is  a  constant  symptom  in  both  form-. 
In  the  external  or  pericranial  form  a  swelling  soon  appears  which  is 
adherent  to  the  bone,  over  which  the  skin  is  movable  at  first,  and  which 
is  firm  and  tender.  Soon  this  softens  and  breaks  down,  giving  rise 
to  a  characteristic  syphilitic  ulcer.  In  the  internal  or  endocranial 
variety,  on  the  other  hand,  there  is  no  visible  change  in  the  contour 
of  the  skull.  These  swellings  may,  if  they  attain  sufficient  size,  give 
rise  to  symptoms  referable  to  pressure  on  the  central  nervous  system, 
either  those  of  irritation  or  paralysis. 

Treatment. — Treatment  should  be  antisyphilitic  and  the  prognosis 
is  good.  When  sequestra  have  formed  which  are  inclosed  by  an 
involucrum,  an  operative  removal  will  be  necessary  to  insure  a  com- 
plete healing  and  recovery. 


THE  BRAIN. 

Injuries  and  diseases  of  the  brain  result,  as  in  other  organs,  in 
stimulating  or  paralyzing  its  various  functions.  The  brain,  so  often 
considered  as  a  single  organ,  is  in  reality  a  collection  of  organs  which 
differ  from  one  another  both  in  structure  and  function  to  as  great 
a  degree  as,  for  instance,  do  the  organs  in  the  abdomen;  and  the 
central  nervous  system  is  in  reality  a  system  of  organs  in  the  true 
sense  of  that  term.  The  fact  that  these  organs  in  the  brain  are  more 
intimately  bound  up  with  one  another  has  given  rise  to  the  frequent 
misconception  that  the  brain  is  a  single  organ.  It  is  through  an  exact 
knowledge  of  the  functions  of  these  different  cerebral  organs,  or 
constituent  parts  of  the  nervous  system,  that  we  are  enabled  to  deter- 
mine the  site  of  any  given  lesion  of  the  central  nervous  system.  There 
are  many  functions  of  these  organs  of  which  we  are  quite  ignorant, 
and  so  oftentimes  we  are  unable  to  located  exactly  the  site  of  a  given 
lesion,  although  we  may  know  that  the  affection  must  be  situated 
somewhere  within  the  brain.  The  nature  of  the  nerve  impulse,  which 
is  the  result  or  product  of  the  activity  of  the  nervous  tissue,  is  itself 


77/ a:  BRAIN  345 

not  understood  and  we  can  judge  of  any  disarrangement  of  this  nerve 
impulse,  whether  qualitative  or  quantitative,  only  by  noting  a  change 
in  the  function  of  some  other  tissue,  which  reacts  in  a  certain  manner 
as  a  result  of  a  given  nerve  impulse.  For  example,  the  impairment  of 
nerve  impulse  in  a  motor  nerve  can  only  be  determined  by  examining 
the  function  of  the  muscle  or  muscles  supplied  by  that  nerve,  and  not 
by  directly  examining  the  nerve  impulse,  which  we  cannot  measure 
and  the  very  nature  of  which  we  do  not  know. 

The  nervous  tissue  of  the  brain  is  composed  of  the  neurones,  the 
nerve  cell  and  its  axis-cylinder  process,  and  the  neuroglia  or  supporting 
stroma,  which  binds  the  numerous  neurones  together.  This  is  richly 
supplied  with  bloodvessels  and  within  its  interstices  there  is  a  certain 
amount  of  cerebrospinal  fluid  and  lymph.  The  function  of  the  neurone, 
or  the  nerve  impulse'  may  be  interfered  with  either  by  severing  the 
connection  between  the  end  organ  and  the  nerve  cell  so  that  the  nerve 
impulse  does  not  reach  the  end  organ,  or  by  interfering  with  the 
function  of  the  nerve  cell  by  which  the  nature  of  the  nerve  impulse 
is  altered  either  in  quality  or  quantity.  This  may  be  accomplished 
by  destruction  of  the  constituents  of  the  neurone,  either  cell  or  axis 
cylinder,  or  by  interfering  with  their  nutrition  to  such  a  degree  that 
they  either  do  not  functionate  normally  or  cease  to  functionate  entirely. 
Therefore  the  symptoms  of  a  lesion  in  the  brain  result  from  either  a 
destruction  of  brain  tissue  or  an  interference  with  its  nutrition,  and 
the  symptoms  from  one  cause  may  not  differ  from  those  of  the  other. 
Depending  on  the  degree  of  interference  in  the  nutrition,  however,  we 
find  that  there  is  a  great  difference  in  the  resulting  symptoms,  and  we 
distinguish  the  irritative  and  paralytic  type  of  symptom. 

By  the  term  irritative  symptom  is  meant  the  reaction  which  takes 
place  as  the  direct  result  of  a  nerve  impulse  set  in  motion  by  an  abnor- 
mal stimulus.  The  stimulus  may  be  abnormal  in  quality,  as  electrical 
stimulation  of  motor  cortex,  or  in  quantity,  as  the  stimulation  of  the 
respiratory  centre  by  insufficiently  oxygenated  blood,  or  in  both  quality 
and  quantity,  as  the  stimulation  by  the  presence  of  pus  in  the  meninges. 

By  the  term  paralytic  symptom  is  meant  the  failure  to  obtain  a 
reaction,  as  great  in  amount  as  normal,  from  a  given  stimulus. 

The  neurones  depend  on  a  constant  supply  of  well  oxygenated  blood 
in  order  to  functionate  properly.  On  the  withdrawal  of  this  supply 
they  cease  immediately  to  send  out  impulses,  although  they  may 
remain  viable  a  long  time  after  they  cease  to  functionate;  therefore 
the  symptoms  of  cerebral  lesions  depend  in  great  measure  on  the 
disturbances  of  the  circulation  of  the  blood  in  the  brain. 

Cerebral  localization,  or  what  is  a  better  term,  the  functions  of  the 
various  organs  of  the  central  nervous  system,  may  be  conveniently 
taken  up  by  following  the  anatomical  divisions  of  the  brain  which 
are  familiar  to  all. 

A.  Cortex  of  Cerebral  Hemisphere  is  composed  of  portions  which 
differ  from  one  another  histologically  in  structure  and  physiologically 


346 


INJURIES  AND  DISEASES  OF  HEAD  AND  BRAIN 


in  function.     Figs.  175  and  176  show  the  portions  of  the  cortex  whose 
function  is  known.     Both  are  adapted  from  Campbell. 


Fig.  175. — Lateral  aspect  of  brain.     (After  Campbell.) 

I.  Precentral  or  Motor  Area. — The  area  of  voluntary  muscular  move- 
ment is  situated  in  the  posterior  two-thirds  of  the  ascending  frontal 
convolution  and  the  anterior  boundary  of  the  Rolandic  fissure,  infe- 


Fig  176. — Mesial  aspect  of  brain.     (After  Campbell.) 

riorily  almost,  but  not  quite,  to  its  lower  end;  on  the  mesial  surface  a 
small  area  anterior  to  the  Rolandic  fissure,  on  the  paracentral  lobule. 


THE  BRAIN  347 

The  portions  of  the  body  controlled  by  this  area  are  from  above 
downward,  foot,  ankle,  leu',  knee  and  thigh;  trunk;  shoulder,  arm 
elbow,  forearm,  wrist,  and  hand;  face,  lips,  tongue,  larynx  and  palate. 

II.  Intermediate  Precentral  Area  is  the  area  controlling  skilled  or 
complex  movements  of  an  associated  kind.  Posteriorly  it  immediately 
joins  the  precentral  area  and  extends  forward  on  the  paracentral 
lobule  to  the  posterior  portion  of  marginal  gyrus,  limited  below  by  the 
callosomarginal  fissure,  while  on  the  lateral  surface  it  extends  forward 
on  the  superior  frontal  gyrus,  posterior  end  of  middle  frontal  gyrus,  and 
extending  forward  to  include  almost  the  entire  inferior  frontal  gyrus, 
including  part  of  pars  basil aris,  all  of  pars  triangularis  and  the  pars 
orbitalis  up  to  transverse  orbital  sulcus.  The  skilled  movements 
of  an  associated  kind  are  the  centre  of  motor  speech,  "Broca's  centre" 
in  the  inferior  frontal  convolution  on  left  side;  cheirographic  centre, 
in  the  middle  frontal  gyrus,  that  is,  the  region  contiguous  to  the 
portion  of  the  precentral  area  which  controls  voluntary  muscular 
movements  of  the  hands.  In  general  there  is  in  the  intermediate 
precentral  area  a  sequential  disposition  of  centres  for  the  control  of 
higher  evolutionary  movements,  following  the  same  order  from  above 
downward  as  that  observed  in  the  precentral  area  proper. 

III.  Postcentral  Area  is  the  "arrival  platform"  for  the  reception 
of  sensory  stimuli  which  have  travelled  up  from  the  periphery.  That 
is,  it  is  the  centre  of  common  sensation.  Anteriorly  it  extends  from 
the  precentral  area  in  the  fissure  of  Rolando  to  the  midline  of  the 
postcentral  gyrus  on  the  lateral  surface  of  the  hemisphere,  while  on 
the  mesial  surface  it  extends  on  the  paracentral  lobnle  backward  from 
the  fissure  of  Rolando. 

IV.  Intermediate  Postcentral  Area  is  the  region  where  there  occurs 
the  elaboration  of  the  crude  sensory  impulses  and  the  differentiation 
of  them  into  the  various  kinds  of  sensation.  On  the  mesial  surface  it 
joins  the  intermediate  precentral  area  on  the  paracentral  lobule  and 
extends  backward  to  the  callosomarginal  fissure,  on  the  lateral  surface 
it  extends  backward  to  the  sulcus  postcentrals  superior  and  inferior. 

V.  Visuosensory  Areas  in  each  hemisphere  receive  the  primary  im- 
pressions from  the  homonymous  halves  of  the  retinal  fields.  The  area 
extends  on  either  side  of  the  posterior  part  of  calcarine  fissure  and  on 
the  lower  wall  of  the  portion  of  the  fissure  anterior  to  its  junction  with 
the  parieto-occipital  fissure. 

VI.  Visuopsychic  Area  controls  the  interpretation  and  synthesising 
of  the  primary  visual  impressions.  It  is  an  area  which  surrounds 
the  visuosensory  region  and  thus  occupies  the  cuneus  portion  of 
parietal  and  temporal  lobes. 

MI.  Auditosensory  Area  receives  the  primary  simple  auditory 
stimuli.     It  corresponds  to  the  transverse  temporal  gyri  of  Heschl. 

VIII .  Auditopsychic  Area  interprets  the  primary  auditory  stimuli 
and  occupies  the  posterior  three-fifths  of  the  superior  temporal 
convolution. 


348         INJURIES  AND  DISEASES  OF  HEAD  AND  BRAIN 

IX.  Olfactory  Area,  which  is  the  seat  of  the  sense  of  smell,  is  limited 
to  the  gyrus  hippocampus. 

B.  Corpus  Callosum. — Lesions  in  the  corpus  callosum  give  rise  to 
apraxia.  This  occurs  on  left  side  in  right-handed  people  and  vice 
versa.  Apraxia  is  the  inability  of  a  patient  to  carry  out  from  memory 
a  designated  act,  as  the  use  of  a  hammer  or  a  saw.  When  this  loss  is 
incomplete  it  is  spoken  of  as  dyspraxia. 

C.  Optic  Thalamus. — Lesions  in  the  thalamus  give  symptoms  only 
when  situated  in  the  posterior  portion.  They  are  often  associated  with 
lesions  of  the  optic  radiation.  The  thalamic  syndrome  consists  of  a 
moderate  hemianesthesia  and  hemiparesis.  This  latter  is  not  asso- 
ciated with  contracture.  There  is,  however,  a  persistent  exaggeration 
of  the  reflexes.  There  is  also  a  hemiataxia  and  hemiasteriognosis. 
On  the  side  affected  there  may  be  constant  pain  and  paresthesia, 
chorioid  and  athetoid  movements  are  common.  Painful  stimuli,  as 
pin  pricks,  give  rise  to  greater  discomfort  than  on  the  normal  side. 

D.  Midbrain. — Lesions  near  the  corpora  quadrigemina  and  crura 
cerebri  give  rise  to  visual  disturbances,  as  loss  of  acuteness  of  vision  and 
paresis  of  the  associated  ocular  muscles;  paresthesia  on  both  sides  of 
body  and  ataxia  of  extremities  is  frequent.  At  times  choreo-athetoid 
movements  develop  and  there  may  be  a  contralateral  diminution  of 
hearing. 

There  may  be  hemiplegia  on  the  side  opposite  to  the  lesion,  hemi- 
anesthesia on  the  side  of  the  lesion,  together  with  an  ophthalmoplegia 
on  the  side  of  the  lesion  (involvement  of  motor  occuli  nucleus). 

E.  Cerebellum. — Lesions  of  the  cerebellum  may  have  definite  focal 
signs,  among  them  the  following  should  be  mentioned : 

Cerebellar  ataxia  causes  a  staggering  similiar  to  the  gait  of  a  man 
intoxicated  by  alcohol.  There  is  an  asynergia,  that  is,  a  tendency  to 
incoordination  between  the  action  of  the  muscles  of  the  trunk  and  of 
the  lower  extremities,  whereby  the  trunk  may  remain  stationary 
while  the  legs  move  forward,  or  the  legs  stop  walking  and  the  trunk 
continues  to  move  forward.  There  is  also  a  tendency  to  fall  toward 
the  side  of  the  lesion  if  in  the  hemispheres,  to  fall  backward  or  forward 
if  in  the  central  vermes.  In  severe  cases  patients  are  not  able  to  remain 
erect. 

Dizziness  is  a  true  rotatory  dizziness,  the  patient  feels  as  if  he  were 
turning  over  or  that  objects  about  him  were  going  round.  This  is 
usually  associated  with  nystagmus. 

Nystagmus  is  frequently  present,  but  may  be  observed  in  lesions 
elsewhere  than  in  the  cerebellum.  It  is  most  pronounced  with  the  eyes 
in  an  extreme  lateral  position,  and  then  most  marked  in  the  abducted 
eye.  The  movements,  especially  of  the  upper  extremity,  are  often 
ataxic  and  there  may  even  be  an  intention  tremor. 

F.  Pons. — Lesions  of  the  pons  result  in  a  paralysis  of  the  facial 
muscles  and  of  the  extremities  on  the  same  side.  This  occurs  from 
lesions  in  the  upper  level  of  the  pons  before  facial  fibres  decussate. 


CRANIAL  TOPOGRAPHY  349 

In  the  lower  level  of  the  pons  below  decussation  of  facial  fibres  there 
will  be  paralysis  of  face  on  the  side  of  lesion  and  of  limbs  on  the  side 
opposite  to  lesion,  alternate  paralysis.  Sensory  disturbances  may 
occur  if  lesion  is  in  tegmentum. 

G.  Medulla  Oblongata. — Lesions  here  are  mainly  pyramidal  lesions 
with  a  crossed  glossopharyngeal,  vagal,  and  hypoglossal  hemiplegia. 

CRANIAL  TOPOGRAPHY. 

To  guide  the  surgeons  in  opening  the  skull  to  attack  lesions  in  certain 
definite  locations,  the  relation  of  the  chief  fissures  and  convolutions 
to  certain  external  landmarks  is  important.  By  determining  the 
position  of  the  fissure  of  Rolando,  the  fissure  of  Sylvius,  and  the 
parieto-occipital  fissure,  one  can  locate  with  reasonable  accuracy  any 
of  the  well-known  cortical  centres. 

To  locate  the  fissure  of  Rolando,  measure  the  distance  from  the 
glabella  to  the  external  occipital  protuberance,  mark  a  point  one-third 
of  an  inch  behind  the  centre  of  this  line,  and  from  this  point  draw  a 
line  obliquely  downward  and  forward  three  and  a  half  inches  in  length 
at  an  angle  of  67  degrees  with  the  median  line.  To  locate  the  fissure 
of  Sylvius,  draw  a  line  from  the  lower  margin  of  the  orbit  backward 
through  the  centre  of  the  external  auditory  meatus;  draw  a  second 
line  parallel  with  this  from  the  external  angular  process  of  the  frontal 
bone  backward  for  a  distance  of  an  inch  and  a  quarter;  make  a  mark 
one-quarter  of  an  inch  above  this  point.  Next  find  the  most  prominent 
portion  of  the  parietal  eminence,  and  make  a  second  mark  three- 
quarters  of  an  inch  below  this  eminence;  a  line  connecting  these  two 
points  will  lie  directly  over  the  fissure  of  Sylvius.  To  find  the  parieto- 
occipital fissure,  continue  the  line  of  the  fissure  of  Sylvius  backward 
until  it  intersects  the  median  line.  The  fissure  lies  immediately 
beneath  the  junction  of  these  two  lines.  The  lower  margin  of  the 
occipital  lobe  and  the  attachment  of  the  tentorium  will  be  indicated 
by  a  line  drawn  from  the  upper  margin  of  the  external  auditory  meatus 
to  the  occipital  protuberance.  The  cerebellum  lies  below  this  line. 
The  lateral  sinus  extends  along  this  line  from  the  occipital  protuberance 
forward  to  a  point  one  inch  behind  the  meatus;  it  then  passes  downward 
toward  the  mastoid  process. 

The  main  trunk  of  the  middle  meningeal  artery  lies  at  a  point 
an  inch  and  three-quarters  above  the  zygoma  and  an  inch  and  a 
half  behind  the  external  angular  process  of  the  parietal  bone. 

Charles  K.  Mills,  in  1902,  from  the  facts  then  available  regarding 
cerebral  localization  and  cranial  topography,  published  a  paper 
giving  seven  lateral  cranial  areas  for  osteoplastic  operations,  with 
syndromes  for  each  region.  A  glance  at  Figs.  177  and  178  will  give 
a  general  idea  of  the  principal  well-established  areas.  These  areas 
are  shown  in  Fig.  179  and  the  corresponding  syndromes  quoted  from 
his  original  article. 


350  INJURIES  AND  DISEASES  OF  HEAD  AND  BRAIN 

In  each  case  the  symptoms  of  irritation  or  destruction  of  the  region 
are  given  first,  afterward  those  of  advancing  pressure. 


CONCRETE   CONCEPT 

Fig.  177. — Side  view  of  human  brain,  showing  localization  of  functions.     (Charles  K. 

Mills.) 


Fig.    178. — View  of  the  mesial  surface  of  the  human   brain,   showing   localization   of 
functions.     (Charles  K.  Mills.) 

A.  Higher    Psychical    Area. — Interference    with    higher    psychical 
processes  as  shown  in  lack  of  power  of  sustained  attention,  impairment 


CRANIAL  TOPOGRAPHY 


351 


of  the  faculties  of  reason,  comparison  and  judgment;  mental  obtuse- 
ness;  relative  optimism;  sometimes  mild  hallucinations  and  delusions. 
Among  the  most  likely  compression  and  invasion  symptoms  are 
motor  agraphia,  motor  aphasia,  monoplegia  or  hemiplegia.  On  the 
negative  side  are  absence  of  anesthesia,  cutaneous  or  muscular; 
astereognosis,  hemianopsia,  word  blindness,  word  deafness,  and 
paraphasia. 

B.  Motor  Speech  Area. — Motor  aphasia,  usually  associated  with 
some  motor  agraphia,  and  paresis,  especially  of  the  face.  More 
complete  hemiplegia  may  indicate  compression  or  invasion,  as  may 
also  some  psychical  disturbance.  On  the  negative  side  absence  of 
the  same  symptoms  as  given  for  area  A. 

C.  Motor  Area. — Monoplegia  or  hemiplegia,  spasms  usually  begin- 
ning in  one  limb  or  in  one  side  of  the  face,  and  usually  either  confined 
or  more  marked  in  the  half  of  the  body  opposite  to  the  side  of  the  lesion. 


Fig.  179 


Tonic  spasticity  is  usually  present,  and  both  the  superficial  and  deep 
reflexes  are  much  exaggerated,  persistent  ankle  clonus  and  the  Babinski 
response  being  present.  Motor  aphasia  and  agraphia  may  be  com- 
pression and  invasion  symptoms  when  the  tumor  spreads  cephalad, 
or  affections  of  cutaneous  and  muscular  sensibility  and  astereognosis 
when  it  increases  caudad.  Psychical  symptoms,  except  those  due 
to  general  cerebral  irritation  and  visual  and  auditory  symptoms,  are 
usually  absent. 

D.  The  Stereognostic  Area. — Astereognosis  and  hemiataxia,  im- 
pairment of  muscular  sensibility  and  of  cutaneous  sensibility;  the 
superficial  reflexes  usually  impaired;  the  Babinski  response  not  present, 
but  the  normal  metatarsophalangeal  response  often  absent,  that  is, 
the  toes  not  moving  from  irritation  of  the  sole  of  the  foot;  the  deep 
reflexes  practically  normal.  Frequent  compression  and  invasion 
symptoms  are  gradually  augmenting  hemiparesis,  gradually  increasing 


352  INJURIES  AND  DISEASES  OF  HEAD  AND  BRAIN 

reflexes  up  to  the  point  of  exaggeration,  and  hemianopsia.  Higher 
physical  symptoms  absent  and  aphasias  usually  absent;  sensory 
aphasia  present  at  times  when  the  tumor  spreads  backward  and 
downward. 

E.  The  Auditory  Area. — Word  deafness,  partial  or  complete; 
verbal  amnesia  and  paraphasia.  Compression  and  invasion  symptoms 
may  be  paresis  or  paralysis;  visual  symptoms,  such  as  word  blindness 
and  hemianopsia,  and  impairment  of  cutaneous  and  muscular  sensi- 
bility. Reflexes  usually  not  much  altered.  Higher  psychical  symp- 
toms, motor  agraphia,  motor  aphasia,  and  astereognosis  usually  absent. 

F.  The  Higher  Visual  Area. — Word  and  letter  blindness  and 
verbal  amnesia.  Compression  and  invasion  symptoms,  chiefly  auditory 
symptoms  and  hemianopsia,  although  astereognosis,  ataxia,  and 
motor  disturbances  may  be  present.  The  Wernicke  reaction,  motor 
disorders,  and  higher  psychical  disturbances  are  usually  absent; 
and  the  deep  and  superficial  reflexes  in  the  extremities  are  usually 
not  altered.  The  superficial  reflexes  are  most  likely  to  be  impaired, 
owing  to  the  anesthesia. 

G.  The  Lower  Cortical  Visual  Area. — Hemianopsia  often  associated 
with  forms  of  word  blindness  when  the  tumor  is  of  considerable  size; 
other  localizing  phenomena  usually  absent. 


INJURIES  OF  THE  BRAIN. 

Concussion.— Concussion  of  the  brain  may  be  defined  as  a  condition 
of  impaired  or  suspended  cerebral  function,  resulting  in  a  loss  of 
consciousness,  temporary  or  prolonged,  due  to  a  sudden  and  violent 
jarring  of  the  brain.  The  cause  of  this  condition  may  be  a  fall  or  a 
blow  on  the  head,  with  or  without  fracture,  or  a  fall  upon  the  buttocks, 
the  force  being  transmitted  through  the  vertebral  column.  Many 
theories  have  been  propounded  to  account  for  the  symptoms  of  con- 
cussion. Recent  investigations,  however,  show  that  in  pure  concussion 
the  only  structural  change  may  be  a  condition  of  shrinkage,  changed 
outline  and  chromatolysis  of  the  ganglion  cells,  similar  to  that  produced 
by  exhaustion  or  starvation. 

Symptoms. — The  symptoms  of  concussion  vary  greatly  in  degree. 
As  a  rule,  they  are  most  pronounced  immediately  following  the  injury 
and  progressively  improve.  An  example  of  the  simplest  form  would 
be  the  slight  giddiness  and  visual  disturbance  commonly  spoken  of  as 
"seeing  stars,"  which  one  frequently  experiences  for  a  moment  after  a 
sudden  blow  on  the  head.  A  more  severe  type  would  be  illustrated 
by  the  sudden  suspended  consciousness  and  complete  muscular 
relaxation  which  follow  a  "knock-out"  blow  on  the  angle  of  the  jaw. 
Recovery  from  such  a  blow  usually  takes  place  in  a  few  seconds,  but 
for  several  minutes  thereafter  the  individual  seems  dazed  and  not 
quite  in  touch  with  his  surroundings.     Later  a  feeling  of  weakness  and 


INJURIES  OF  THE  BRAIN  353 

indisposition  to  physical  or  mental  exertion  may  be  present  for  several 
hours. 

We  may  thus  distinguish  two  groups,  the  mild  and  the  severe  cases. 

Mild  Cases. — Following  a  blow  or  fall  there  supervenes  unconscious- 
ness accompanied  or  preceded  by  dizziness;  the  patient  sees  stars 
before  the  eyes  or  has  a  ringing  in  the  ears.  There  then  follows  a 
weakness  in  the  knees  and  other  muscles;  the  arms  fall  loose  at  the 
sides,  the  face  becomes  pale,  the  look  is  fixed  and  expressionless  and  the 
eyelids  close.  The  respirations  are  so  shallow  that  it  seems  as  though 
the  person  was  not  breathing  at  all;  the  pulse  is  small,  thready  and 
usually  slow. 

In  the  mild  cases  this  condition  does  not  last  long;  the  pulse  becomes 
fuller,  there  are  several  deep  breaths,  the  patient  opens  the  eyes, 
stretches  out  his  arms,  stands  up.  In  walking  he  may  be  a  trifle 
unsteady  in  his  gait,  complain  of  headache,  ringing  in  the  ears  and 
extreme  weariness  and  lassitude.  This  gradually  becomes  better  and 
in  a  short  time  the  patient  returns  to  work. 

Severe  Cases. — At  the  moment  of  the  blow  or  fall  the  patient  crumples 
up  and  remains  unconscious  and  motionless.  It  is  not  possible  to 
awaken  him.  He  does  not  react  to  corneal  reflex  or  to  skin  irritation 
or  stimulation.  The  pupil,  which  is  at  times  contracted,  at  times 
dilated,  reacts  to  bright  light,  and  when  water  is  placed  in  the  mouth 
it  is  swallowed.  The  face  is  pale.  The  surface  of  the  body  and  the 
extremities  are  cold.  The  respirations  are  irregular  and  every  now 
and  then  will  occur  a  deep,  long-drawn  sigh. 

The  pulse  is  small,  somewhat  irregular,  usually,  but  not  always, 
slow.     There  may  be  involuntary  urination  and  defecation. 

Vomiting  may  occur  several  times  immediately  following  the  injury. 
Finally  the  respiration  becomes  deeper,  the  pulse  becomes  fuller 
and  stronger.  The  body  becomes  warm  and  motion  returns.  The 
patient  may  remain  in  this  condition  for  hours  or  even  days,  with 
complete  loss  of  consciousness.  He  then  becomes  restless  and  finally 
regains  consciousness.  He  may  answer  questions  correctly,  but  all 
recollection  of  the  injury  or  events  immediately  preceding  it  may 
be  lost,  never  to  be  regained.  At  times  he  may  have  forgotten 
events  several  days  preceding  the  injury.  There  now  follows  a  stage 
of  exaltation.  The  pulse  is  frequent  and  hard,  the  temperature 
is  raised,  the  face  is  flushed,  the  pupils  contracted.  The  patient 
complains  of  headache,  restlessness  and  pains  in  the  limbs.  This 
stage  may  last  a  variable  time.  The  longer  the  symptoms  last  the 
greater  is  the  possibility  that  other  lesions  have  occurred. 

Diagnosis. — Only  in  the  cases  in  which  improvement  supervenes 
rapidly,  when  the  patient  recovers  shortly  after  the  injury,  can  we 
speak  with  any  assurance  of  a  pure  concussion.  In  the  severe  cases 
the  diagnosis  must  be  tentative  at  first  because  of  the  frequent  occur- 
rence that  other  lesions  are  present  or  may  supervene,  as  compression, 
contusion  or  meningitis. 
23 


354  INJURIES  AND  DISEASES  OF  HEAD  AND  BRAIN 

Concussion  alone  never  causes  a  gradual  increase  in  the  severity 
of  the  symptoms  after  the  onset,  as  deepening  of  the  coma,  continued 
slowing  of  the  pulse,  convulsive  movements,  convulsions  or  paralysis. 

Treatment. — A  patient  who  has  had  a  mild  concussion  probably 
will  require  no  treatment,  although  he  may  complain  of  some  muscular 
weakness  for  several  days.  Severe  cases  should  be  kept  in  bed,  with 
the  head  lowered.  The  application  of  external  warmth  is  indicated, 
and  if  he  can  swallow,  small  quantities  of  fluid  nourishment.  Cathar- 
tics should  be  given  to  insure  a  free  movement  from  the  bowels  each 
day.  A  period  of  prolonged  unconsciousness  should  make  one  examine 
carefully  for  other  possible  conditions. 

Compression  of  the  Brain. — Normally  the  cavity  of  the  skull  is 
completely  filled  by  nervous  tissue,  the  brain  and  the  cranial  nerves, 
by  the  bloodvessels  filled  with  blood,  arteries,  veins  and  capillaries, 
and  by  the  cerebrospinal  fluid,  contained  in  the  subarachnoid  space 
and  the  ventricles  of  the  brain.  As  a  substance  each  one  of  these 
elements  is  as  non-compressible  as  water.  The  brain  is  a  vascular 
structure,  well  supplied  by  arteries  with  a  rich  capillary  network,  drain- 
ing into  numerous  large  veins,  which  empty  into  the  sinuses  of  the  dura 
mater.  It  is  surrounded  by  cerebrospinal  fluid  and  may  be  said  to 
float  in  a  water-bed  within  the  cranial  cavity.  By  the  term  compres- 
sion of  the  brain  is  meant  that  the  bloodvessels  in  the  nervous  tissue 
are  compressed  and  emptied  of  their  contents,  whereby  the  circulation 
within  them  is  deranged  and  there  results  an  interference  with  the 
nutrition  of  various  portions  of  the  brain,  particularly  in  regard  to  the 
supply  of  oxygen.  Thus  compression  of  the  brain  is  solely  a  manifesta- 
tion of  a  circulatory  disturbance  in  the  brain.  This  disturbance  may 
be  a  local  one  confined  to  a  limited  area,  or  a  general  one  resulting  in 
more  or  less  complete  asphyxiation  of  the  entire  brain.  In  local 
pressure  the  interference  with  the  circulation  is  most  marked  in  the 
immediate  vicinity  of  the  compressing  agent,  and  there  is  about  this 
an  ever  widening  area,  showing  a  progressively  diminishing  degree  of 
circulatory  derangement.  In  general  pressure,  the  entire  brain  being 
involved,  the  oxygenation  of  the  vital  centres  grouped  in  the  medulla 
is  interfered  with.  As  soon  as  the  vasomotor  centre  feels  the  effect 
of  asphyxiation  it  sends  out  impulses  which  raise  the  general  arterial 
pressure,  in  the  endeavor  to  overcome  the  force  compressing  its  blood- 
vessels and  so  diminishing  its  supply  of  oxygenated  blood.  The  high 
blood-pressure  does  not  remain  at  a  fixed  level  but  varies  in  rhythmic 
waves  (Traube-Herring  waves),  and  when  the  intracranial  tension 
becomes  so  great  that  the  blood-pressure  variations  rise  above  and 
fall  below  its  level,  there  result  periods  of  anemia  at  the  lowest  point 
of  the  wave,  followed  by  periods  of  oxygenation  at  the  crest  of  the 
wave.  During  the  period  of  anemia  the  respiratory  centre  ceases  to 
functionate,  the  respiratory  act  ceases,  to  recommence  when  it  is 
again  supplied  with  blood.  This  gives  rise  to  the  Cheyne-Stokes  type 
of  respiratory  rhythm. 


PLATE    XII 


Emissary  vi  in 

1  /  it  mis  lacuna  \  _  Sup.  sagittal  sinus 

\        Cerebral  vein 


Diploic  vein  \ 


Arachnoid  granulation 


Meningeal  vein 


Subdural  cavity 
Subarachnoid  cavity 


a  mater 
Arachnoid 

Cerebral  cortex 


Diagrammatic  Representation  of  a  Section  Across  the  Top  of  the  Skull, 
Showing  the  Membranes  of  the  Brain,  etc.     (Modified  from  Testut.) 


INJURIES  OF  THE  BRAIN  355 

For  clinical  purposes  we  can  conveniently  divide  the  symptoms  into 
four  stages  (Kocher,  Ciishing). 

First  stage,  or  stage  of  compensation  corresponds  to  a  mild  degree 
of  pressure  resulting  in  a  squeezing  out  of  the  cerebrospinal  fluid  from 
the  immediate  neighborhood  of  the  compressing  force,  a  slight  inter- 
ference in  the  venous  return  giving  rise  to  a  moderate  venous  congestion. 
The  symptoms  are  often  imperceptible,  a  mild  degree  of  headache, 
some  slight  mental  dulness  and  at  times  symptoms  referable  to  the  site 
of  the  lesion  in  the  brain.     These  latter  will  be  irritative  in  character. 

Second  stage,  or  stage  of  beginning  evident  pressure,  is  coincident 
with  an  impaired  circulation  over  an  extended  area  whereby  there  is  a 
pronounced  venous  stasis.  There  is  a  certain  degree  of  vertigo  and 
restlessness  accompanied  by  a  severe  headache.  The  pulse  is  often 
slow  from  stimulation  of  the  vagus.  As  pressure  continues  the 
sensorium  is  affected  and  delirium  develops.  There  may  or  may  not 
be  a  papiledema  and  a  slight  rise  in  general  blood-pressure.  The 
optic  disk  shows  a  tortuosity  of  the  veins.  At  times  there  is  a  con- 
gestion of  the  face. 

Third  stage,  or  stage  of  pronounced  pressure.  Here  the  pressure  has 
increased  sufficiently  to  empty  the  capillaries  and  give  rise  to  an 
extended  capillary  anemia  which  is  intermittent  because  of  the  fluctua- 
tions in  the  blood-pressure.  The  vasomotor  and  other  centres  in 
the  medulla  are  affected.  The  rhythmic  fluctuations  in  the  heightened 
blood-pressure  give  rise  to  the  Cheyne-Stokes  respiratory  rhythm, 
variations  in  the  size  of  the  pupils  and  restlessness  alternating  with 
stupor.  The  patient  is  more  restless  during  the  high  point  in  the  blood- 
pressure  curve  and  at  the  same  time  the  respiratory  act  occurs.  The 
pulse  is  slow,  50  or  below,  full,  bounding  in  character.  The  face  is 
congested  and  not  infrequently  becomes  cyanotic.  There  is  a  pro- 
nounced degree  of  choked  disk.  The  stupor  and  coma  become  more 
profound,  the  reflexes  are  abolished  and  the  compensatory  factors 
of  vasomotor  impulse  begin  to  fail. 

Fourth  stage,  or  stage  of  paralysis  follows  the  last,  at  times  with 
alarming  rapidity,  at  others  more  gradually.  The  vasomotor  centre 
suffers  with  the  others;  its  efforts  at  compensation  fail,  the  blood- 
pressure  falls,  the  pulse  becomes  rapid,  irregular  and  small,  the  coma 
deepens,  general  muscular  tone  vanishes  with  complete  relaxation, 
the  cerebral  functions  cease  and  patient  dies  from  respiratory  paralysis. 
Prognosis. — The  prognosis  is  always  grave.  The  causative  factor, 
the  rapidity  in  the  development  of  the  symptoms  and  the  degree  to 
which  they  have  advanced,  will  influence  materially  the  ultimate 
outcome.  Each  case  must  be  considered  on  its  merits,  but  those  cases 
in  which  the  failure  in  compensation  has  appeared  are  especially 
serious  and  frequently  do  not  recover  even  with  appropriate  treatment. 
Treatment. — One  should  not  delay  in  relieving  this  condition  until 
there  are  symptoms  of  beginning  paralysis  of  the  medulla  centres. 
The  pulse-rate,  choked  disk,  and  blood-pressure  are  criteria  of  greatest 


356  INJURIES  AND  DISEASES  OF  HEAD  AND  BRAIN 

importance.  The  relief  must  be  attained  by  operation.  A  craniotomy 
to  relieve  the  pressure  is  indicated.  A  choice  of  the  site  for  the  opening 
in  the  skull  must  be  determined  by  the  probable  site  of  the  cause  of 
the  compression.  The  subtemporal  decompression  offers  the  most 
useful  operation  when  the  site  of  the  lesion  cannot  be  determined  as 
the  resulting  deformity  and  the  danger  of  subsequent  hernia  is 
diminished. 

Contusion  and  Laceration  of  the  Brain. — Contusion  of  the  brain  is 
synonymous  with  laceration  of  the  brain  and  intracerebral  hemorrhage. 
There  occur  varying  degrees  of  destruction  of  brain  tissue.  It  may  be 
the  direct  result  of  trauma,  or  of  the  spontaneous  rupture  of  a  blood- 
vessel. This  latter  has,  up  to  the  present  time,  very  little  interest 
for  the  surgeon.  The  destruction  from  trauma  may  be  directly 
beneath  the  point  of  injury  to  the  skull  or  may  be  at  a  distant  point. 
At  times  it  occurs  at  the  opposite  pole  to  that  struck.  A  frequent 
site  is  the  tip  of  the  temporal  lobe  or  base  of  the  frontal  lobes. 

Symptoms. — There  usually  occur  the  signs  of  a  concussion,  which 
instead  of  clearing  up  promptly,  continue,  or  even  increase  in  intensity, 
with  a  febrile  movement  after  a  few  days.  A  lumbar  puncture  will 
often  reveal  the  presence  of  blood  in  cerebrospinal  fluid.  Convalescence 
is  prolonged,  accompanied  by  more  or  less  persistent  severe  headache, 
restlessness  and  irritability.  It  may  require  several  months  for  a 
patient  to  completely  recover  and  be  restored  to  health  so  that  he  is 
able  to  carry  on  hard  mental  work.  A  severe  laceration  of  the  brain 
may  be  followed  by  permanent  changes  in  a  patient's  character,  or  may 
result  in  an  impairment  of  his  mental  vigor.  At  times  it  is  followed 
by  Jacksonian  epilepsy. 

Prognosis. — A  guarded  prognosis  as  to  ultimate  results  should  be 
given  in  every  case  of  brain  laceration. 

Treatment.— Patient  must  be  confined  to  bed  until  the  fever  has 
subsided  and  until  all  symptoms  of  an  active  process  have  disappeared. 
He  should  not  be  allowed  to  return  to  work  for  several  weeks,  or  until 
he  is  free  from  headache  and  has  regained  his  lost  flesh  and  strength. 
The  occurrence  of  compression  symptoms  may  demand  a  decompressive 
operation  for  their  relief. 

INTRACRANIAL  HEMORRHAGE. 

These  may  be  classified  according  to  the  situation  in  which  the 
extravasated  blood  is  found:  (1)  extradural;  (2)  subdural;  (3)  pial; 
(4)  subpial;  (5)  intracerebral. 

1.  Extradural  Hemorrhage. — The  extravasated  blood  is  situated 
between  the  skull  and  the  dura  mater.  It  is  not  a  common  lesion  in 
its  pure  form,  and  yet  not  by  any  means  a  rarity.  It  is  rare  in  children 
or  infants. 

Pathology. — It  is  always  due  to  injury.  The  blood  accumulates 
between  the  dura  mater  and  the  skull.    The  blood  may  come  from  the 


INTRACRANIAL  HEMORRHAGE  357 

middle  meningeal  artery,  venous  sinuses,  or  diploic  veins.  The  anterior 
branch  of  the  middle  meningeal  is  by  far  the  most  frequent  source, 
less  frequently  its  main  trunk,  or  its  posterior  branch,  and  least  of  all, 
its  middle  branch.  The  venous  sinuses  are  occasionally,  but  not 
frequently,  the  cause  of  extradural  hemorrhage.  The  superior  longi- 
tudinal is  the  most  frequently  injured;  then  the  transverse,  most  often 
at  the  point  of  junction  between  its  transverse  and  the  vertical  portions. 
The  diploic  veins  are  rarely  the  cause  of  this  lesion.  The  train  of 
symptoms  depends  largely  on  the  anatomical  peculiarity  that  the  dura 
is  firmly  adherent  to  the  bone  and  separates  only  very  slowly  as  it  is 
dissected  away  by  the  extravasated  blood.  The  blood  clot  is  apt  to 
be  lens  shaped.  Trauma  always  causes  it  and  the  lesion  usually  is  a 
fractured  skull. 

Symptoms. — There  is  a  history  of  injury  which  is  followed  by  more 
or  less  pronounced  concussion  with  its  attendant  symptoms.  The 
patient  may  completely  recover  from  the  concussion,  and  have  what 
is  spoken  of  as  a  free  interval,  during  which  time  he  may  be  absolutely 
free  from  symptoms.  During  the  free  interval  he  may  not  completely 
clear  up,  and  he  may,  even  before  he  again  loses  consciousness,  develop 
focal  symptoms  which  would  locate  the  site  at  which  the  extravasation 
is  taking  place.  In  injury  to  the  middle  meningeal,  there  will  develop 
oftentimes  irritative  or  paralytic  symptoms  of  the  lower  end  of  pre- 
central  area  in  face  and  arm,  while  on  the  left  side  there  may  be  motor 
aphasia.  After  a  variable  space  of  time  he  will  complain  of  headache, 
nausea,  vomiting;  and  rapidly  passes  into  a  state  of  increased  intra- 
cranial pressure  and  may  pass  through  all  of  its  four  stages. 

There  may  be  focal  symptoms  referable  to  the  cortex.  These  at  first 
may  be  irritative  and  later  be  paralytic,  or  they  may  be  paralytic 
from  the  beginning.  The  rapidity  with  which  the  blood  accumulates 
will  determine  the  duration  of  the  free  interval  and  also  the  train  of 
the  symptoms  of  intracranial  pressure. 

Diagnosis.— Diagnosis  will  be  made  by  a  history  of  injury  which 
may  or  may  not  be  followed  by  unconsciousness  (concussion),  from 
which  the  patient  recovers;  he  then  has  an  interval  during  which  he 
is  free  from  symptoms,  and  later  develops  increasing  symptoms  of 
compression. 

Treatment. — This  should  consist,  in  every  case  in  which  the  diagnosis 
of  extradural  hemorrhage  can  be  established,  in  operative  interference, 
removal  of  the  blood  clot  and  ligation  of  the  vessel  if  necessary.  In 
doubtful  cases  in  which  the  diagnosis  is  probable,  exploration  'also 
offers  the  best  chance.  The  determination  of  the  point  at  which  the 
opening  should  be  made,  in  many  cases  will  be  readily  reached,  in 
others  it  may  be  difficult,  and  it  is  then  justifiable  to  explore  one  side 
and,  if  no  evidence  of  injury  is  found,  immediately  to  explore  the  other. 
The  operative  procedure  should  consist  in  an  exploratory  craniotomy, 
after  determining  the  probable  site  of  the  lesion,  whether  at  the  point 
of  injury  or  in  the  opposite  hemisphere  in  the  case  of  bursting  or  bend- 


358  INJURIES  AND  DISEASES  OF  HEAD  AND  BRAIN 

ing  fractures,  and  in  the  hemorrhages  from  the  middle  meningeal 
artery,  entering  the  skull  at  the  pterion  for  anterior  branch,  centre  of 
squamous  of  temporal  for  middle  branch,  postero-inferior  angle  of 
parietal  for  posterior  branch. 

2.  Subdural  Hemorrhage. — The  extravasated  blood  is  situated 
beneath  the  dura  mater  in  the  meshes  of  the  arachnoid  space.  It  is 
more  frequent  than  the  extradural  hemorrhage  and  may  occur  at  any 
age.  It  is  not  always  preceded  by  trauma.  Any  injury  to  the  pial 
vessels,  sinuses  of  the  dura  mater,  fracture  of  skull,  especially  through 
the  base  with  rupture  of  dura,  will  result  in  the  extravasation  of  the 
blood  in  the  arachnoid  space.  This  is  usually  a  diffuse  extravasation, 
in  which  the  blood  accumulates  about  the  base.  The  blood  spreads 
more  rapidly  in  the  arachnoid  space  than  beneath  the  dura  and 
although  it  may  clot,  it  does  so  more  slowly.  The  cerebrospinal  fluid 
is  blood  tinged  even  down  in  the  spinal  canal. 

Symptoms. — Symptoms  as  a  rule  are  those  of  more  or  less  rapidly 
occurring,  increased,  intracranial  pressure.  At  times  there  may 
intervene  a  free  interval.  This  is  certainly  rare.  The  cerebrospinal 
fluid  obtained  by  lumbar  puncture  will  show  presence  of  red  blood  cells. 

Treatment. — Treatment  must  be  governed  entirely  by  the  course 
of  the  intracranial  pressure.  If,  as  in  man}'  cases,  this  reaches  a 
certain  degree  compatible  with  life  and  remains  stationary,  the  treat- 
ment should  be  expectant,  but  in  the  cases  in  which  the  intracranial 
pressure  steadily  increases,  one  should  not  wait  for  alarming  symptoms 
of  failure  at  compensation  before  he  decompresses  to  relieve  the 
embarrassed  medullary  centres. 

3.  Pial  Hemorrhage. — Pial  hemorrhage  occurs  when  the  blood  is 
extravasated  between  the  two  layers  of  the  pia  mater.  It  disseminates 
widely  and  rapidly.  It  is  seen  frequently  during  operative  procedure 
when  the  cortex  is  handled  roughly.  It  gives  to  the  surface  of  the 
brain  a  peculiar  light  cherry-red  color.  Not  infrequently  it  is  seen  as 
a  peripheral  zone  about  an  area  of  contusion  and  laceration. 

4.  Subpial  Hemorrhage. — Subpial  hemorrhage  is  where  the  blood 
separates  the  pia  mater  from  the  surface  of  the  brain.  The  blood 
often  remains  fluid,  is  disseminated  over  a  limited  area,  and  never 
accumulates  in  any  great  quantity  to  form  a  thick  layer. 

5.  Intracerebral  Hemorrhage. — Intracerebral  hemorrhage,  as  has 
been  stated,  is  closely  allied  to  the  contusion  and  laceration  of  the  brain. 
The  hemorrhages  may  be  the  result  of  a  rupture  of  a  diseased  vessel, 
or  of  an  injury.  The  extravasation  occurs  within  the  cerebral  sub- 
stance, and,  depending  upon  the  rapidity  of  its  accumulation,  will 
appear  an  encapsulated  blood  clot,  or  simply  a  diffuse  infiltration.  At 
times  the  blood  flows  into  and  fills  the  ventricles. 

Symptoms. — A  typical  case  of  spontaneous  intracerebral  hemorrhage 
from  rupture  of  some  diseased  vessel,  the  stroke  of  apoplexy,  will  be 
familiar  to  all;  the  sudden  loss  of  consciousness,  the  alarming  failure  of 
cardiac  and  respiratory  centres  leading  to  death  in  the  severe  cases, 


DISEASES  OF  THE  BRAIN  359 

the  slow  gradual  recovery  with  the  resulting  hemiplegia  phenomena 
in  the  cases  which  recover.  In  left-sided  lesions  the  mental  vigor  of 
the  patients  is  more  apt  to  remain  impaired.  In  the  traumatic  cases 
the  symptoms  and  treatment  do  not  in  any  way  differ  from  those  of 
contusion  or  laceration  of  the  brain. 

DISEASES  OF  THE  BRAIN. 

Septic  Inflammation  of  the  Brain  and  its  Membranes. — Infection  of 
the  intracranial  structures  may  take  place  through  an  open  wound, 
by  the  bloodvessels,  or  by  the  lymphatics.  The  commonest  cause  is 
trauma;  the  others,  in  the  order  of  their  frequency,  are  middle-ear 
disease,  disease  of  the  frontal  sinuses  or  ethmoidal  cells,  suppurative 
lesions  of  the  scalp,  and  metastases  from  other  remote  septic  foci. 
In  fractures  at  the  base  of  the  skull  the  infection  generally  takes  place 
through  a  fissure  which  communicates  with  the  nasal,  pharyngeal, 
or  aural  cavity.  In  compound  fractures  of  the  convexity  infection 
is  often  carried  inward  by  hairs  or  bits  of  clothing  driven  in  by  the 
fracturing  force.  In  middle-ear  disease  and  inflammations  of  the 
accessory  nasal  sinuses,  infection  is  usually  carried  by  direct  extension 
(necrosis  of  bone)  or  through  the  lymphatic  or  venous  channels. 

In  traumatic  cases,  in  which  general  infection  occurs,  and  in  many 
cases  of  spreading  infection  from  local  causes,  the  inflammatory  process 
involves  all  of  the  intracranial  structures,  meninges,  brain  substance, 
sinuses,  and  nerve  trunks.  In  these  cases  it  is  often  impossible  to 
distinguish  clinically  between  the  different  lesions,  the  symptom- 
complex  suggesting  only  a  diffuse  septic  inflammation  which  leads 
rapidly  to  a  fatal  termination.  In  milder  infections  which  spread 
less  rapidly  one  is  often  able  to  make  a  more  specialized  diagnosis. 
These  infections  may  be  classified  by  the  exact  situation  of  the  inflam- 
mation, whether  in  dura  mater,  pia  mater  or  brain. 

Meningitis. — Two  forms  of  meningitis  occur:  pachymeningitis,  or 
inflammation  of  the  dura,  and  leptomeningitis,  or  inflammation  of 
the  pia. 

Acute  External  Pachymeningitis. — Acute  external  pachymeningitis 
is  an  inflammatory  process  situated  between  the  inner  surface  of  the 
skull  and  the  dura  mater.  It  is  usually  the  result  of  compound  fracture 
of  the  skull  which  has  not  wounded  the  dura.  When  such  a  wound 
becomes  infected,  which  often  occurs  from  tightly  closing  a  scalp 
wound  without  drainage,  a  collection  of  pus  forms  on  the  outer  surface 
of  the  dura  which  may  extend  for  a  considerable  distance,  separating 
the  dura  from  the  skull  and  giving  rise  to  a  tumor  which  causes  symp- 
toms of  local  brain-pressure.  It  may  arise  from  a  slow  chronic  or 
subacute,  distinctly  localized  process  of  inflammation  on  a  portion 
of  the  inner  table  of  the  skull.  The  infection  may  have  begun  on 
the  outer  table.  The  disease  is  recognized  by  pain,  throbbing,  edema 
of  the  scalp,  headache,  evidences  of  septic  intoxication,  and  possibly 


3G0  INJURIES  AND  DISEASES  OF  HEAD  AND  BRAIN 

focal  brain  symptoms.  Opening  the  wound,  removing  a  button  of 
bone,  evacuating  the  pus,  irrigation  and  drainage  of  the  cavity  will 
usually  result  in  a  cure,  unless  the  infection  is  carried  by  the  dura] 
veins  to  one  of  the  sinuses,  in  which  case  sinus  thrombosis  and  pyemia 
may  develop. 

Chronic  Internal  Pachymeningitis. — Chronic  internal  pachymeningitis 
is  a  rare  condition,  the  etiology  of  which  is  obscure.  It  is  characterized 
by  a  localized  plastic  inflammation  occurring  on  the  inner  surface  of 
the  dura.  The  plastic  exudate  becomes  highly  vascular;  hemorrhages 
may  occur,  giving  rise  to  symptoms  of  local  or  general  compression. 
The  process  is  an  extremely  slow  one,  is  rarely  diagnosticated,  and  has 
not  received  the  attention  from  surgeons  which  its  importance  merits. 
Munro,  of  Boston,  has  demonstrated  that  surgical  relief  is  sometimes 
possible.  The  symptoms  are,  as  a  rule,  chronic  headache  with  occa- 
sionally well-marked  focal  brain  symptoms.  The  treatment  should 
be  an  exploratory  osteoplastic  resection  of  the  skull,  with  removal  of 
the  clots  and  exudate,  and  subsequent  closure  of  the  wound. 

Acute  Septic  Leptomeningitis. — This  is  the  usual  form  of  meningitis 
which  occurs  after  trauma  and  from  extension  of  a  septic  process  from 
a  neighboring  focus.  It  occurs  also  as  an  epidemic  disease — cere- 
brospinal meningitis — and  as  a  tuberculous  process.  It  is,  however, 
only  with  the  septic  form  that  the  surgeon  has  to  deal.  Following 
an  external  pachymeningitis  an  adhesive  inflammation  occurs  which 
glues  together  the  structures  immediately  beneath  it,  namely,  the 
arachnoid,  pia  and  brain,  and  thus  a  local  leptomeningitis  may  develop. 
When  this  inflammation  continues  and  there  occurs  a  softening  process, 
a  collection  of  pus  may  form  within  the  meshes  of  the  arachnoid 
giving  rise  to  what  is  spoken  of  at  times  as  a  subdural  abscess.  If  on 
the  other  hand  the  infection  is  brought  directly  to  the  pia  mater  by  a 
penetrating  wound  or  the  inflammatory  process  extends  very  rapidly 
before  any  adhesions  can  take  place,  there  occurs  a  generalized  lepto- 
meningitis. Pyogenic  infections  of  the  face  and  scalp,  as  erysipelas, 
furuncle  or  carbuncle  may  give  rise  to  leptomeningitis.  In  this  case 
the  infection  usually  travels  by  a  thrombosis  of  the  diploic  veins  and 
so  gains  access  to  meninges.  Septic  meningitis  may  begin  in  the  pia 
covering  the  convexity  of  the  brain  or  at  the  base.  In  either  case  the 
process  extends  rapidly  and  eventually  involves  the  greater  part 
of  the  membrane,  including  that  portion  lining  the  ventricles.  The 
surface  of  the  brain  is  injected,  edematous,  and  covered  with  fibrin; 
the  cerebrospinal  fluid  is  at  first  cloudy,  but  later  becomes  distinctly 
purulent  and  distends  the  subarachnoid  space  and  ventricles,  causing 
marked  pressure  on  the  brain-substance. 

Symirtoms. — The  symptoms  at  first  are  those  of  cortical  irritation 
— severe  headache,  with  intolerance  of  light  and  sound,  fever,  chills, 
a  rapid  pulse,  and  stiffness  of  the  muscles  of  the  neck.  The 
pupils  are  contracted;  there  are  wild  delirium,  spasmodic  contraction 
of  the  muscles,  and  occasionally  general  convulsions.     As  the  disease 


DISEASES  OF  THE  BUMS  361 

progresses  the  irritative  symptoms  gradually  give  way  to  those  of 
paralysis  of  the  cortical  centres.  There  is  stupor,  the  delirium  becomes 
low  and  muttering,  the  pupils  dilate,  and  symptoms  of  cerebral 
compression  appear.  In  meningitis  limited  to  the  region  of  the  base, 
the  early  headache  and  delirium  may  be  wanting;  the  symptoms  are 
those  of  general  sepsis  and  cerebral  irritation,  followed  by  paralysis 
of  the  cranial  nerves  and  cerebral  compression.  In  doubtful  cases 
lumbar  puncture  may  be  practised,  and  the  fluid  withdrawn  examined 
for  pus  and  micro-organisms. 

Prognosis. — The  prognosis  is  extremely  grave.  Death  may  occur 
at  any  time,  from  two  to  ten  days  from  the  onset  of  the  symptoms. 

Treatment. — The  /treatment  should  consist  in  rest  in  a  darkened 
room,  cold  to  the  head,  cathartics,  low  diet,  and  measures  to  control 
the  early  pain  and  delirium.  The  original  wound,  if  one  is  present, 
should  be  enlarged  and  one  or  more  other  openings  made  in  the  skull 
for  irrigation  and  drainage  of  the  subdural  space.  This  treatment 
thoroughly  carried  out  has  occasionally  been  followed  by  recovery. 
Ventricular  drainage  will  sometimes  be  indicated.  In  the  early 
stages  of  the  infection,  urotropin  is  to  be  recommended. 

Encephalitis.  Acute  encephalitis  is  a  softening  and  inflammation 
of  the  brain  tissue  which  has  no  well-defined  limit-,  surrounded  by  an 
area  of  edema  which  merges  gradually  into  the  normal  brain.  A 
compound  fracture  of  the  skull  associated  with  laceration  of  the  brain, 
which  becomes  infected,  gives  rise  to  it.  Penetrating  wounds  in  which 
the  septic  material  is  carried  deep  into  the  brain  substance,  a  capillary 
thrombosis  of  the  veins  leading  into  the  brain  from  a  neighboring 
septic  focus,  also  may  cause  it.  Such  a  focus  may  be  a  pachymeningitis 
or  an  otitis  media,  acute  or  chronic,  the  last  being  a  frequent  cause,  as 
the  granulations  slowly  erode  the  bony  walls  of  the  middle  ear  and  the 
way  is  opened  for  the  entranceof  micro-organisms  intothecranialcavity. 

Symptoms. — The  symptoms  of  acute  encephalitis  resemble  those  of 
an  acute  septic  meningitis,  or  they  may  be  less  severe,  and  simply 
those  of  local  cortical  irritation  followed  by  pressure-symptoms. 
These  latter  are  largely  due  to  the  pronounced  inflammatory  edema 
which  often  results.  The  symptoms  may  gradually  pass  away  and 
recovery  take  place.  The  termination  of  encephalitis  may  be  in 
death  from  sepsis  or  the  accompanying  meningitis,  in  recovery,  or 
in  the  development  of  an  acute  or  chronic  cerebral  abscess. 

Treatment. — The  treatment  should  consist  in  proper  and  adequate 
drainage  of  the  infected  focus. 

As  abscess  of  the  brain  results  most  frequently  from  middle-ear 
disease;  it  is  generally  located  in  the  temporosphenoidal  lobe  or  in  the 
cerebellum,  the  infection  in  the  former  instance  taking  place  through 
the  roof  of  the  tympanum  and  antrum  of  the  mastoid;  in  the  latter 
through  its  posterior  wall  or  from  a  sinus  thrombosis.  The  location 
of  abscesses  in  other  silent  regions  may  be  suggested  by  scars  and 
evidences  of  previous  injury. 


362         INJURIES  AND  DISEASES  OF  HEAD  AND  BRAIN 

Abscess  of  the  Brain  — Abscess  of  the  brain  results  from  an  enceph- 
alitis which  has  become  encapsulated.  At  first  there  is  an  exudation 
of  serum  and  leukocytes  together  with  a  swelling  of  the  brain  tissue 
and  often  there  is  an  extravasation  of  red  blood  cells  which  gives  rise 
to  what  is  spoken  of  as  red  softening.  Soon  there  supervenes  a  soften- 
ing process  as  the  brain  tissue  disintegrates  and  pus  is  formed.  About 
the  area  of  softening  and  pus  there  is  at  first  a  zone  of  acute  inflamma- 
tion which  shows  a  hyperemia  of  the  vessels,  edema  of  brain,  and 
exudation  of  cells.  The  wall  of  such  an  abscess  is  covered  by  sloughs 
and  exposed  thrombosed  vessels  and  is  rough  and  shaggy  with  shreds 
of  tissue  hanging  from  its  surface.  An  abscess  often  becomes  encap- 
sulated when  the  molecular  disintegration  ceases  and  a  capsule  of 
fibrin  forms  about  it  which  may  in  time  become  vascularized.  Some 
cerebral  abscesses  may  become  absorbed,  or  slowly  but  progressively 
increase  in  size  and  rupture  into  the  ventricles  of  the  brain  or  subdural 
space.     At  times  there  is  more  than  one  abscess  present. 

Symptoms. — There  are  a  number  of  different  courses  which  an  abscess 
of  the  brain  may  pursue.  McEwen  has  drawn  attention  to  the  fact 
that  in  cases  which  are  said  to  be  chronic,  located  in  one  of  the  silent 
areas  of  the  brain  and  giving  rise  to  no  symptoms,  one  must  be  careful 
not  to  confuse  symptoms  not  observed  with  symptoms  not  present. 
There  are  usually  some  signs  if  sought  for  properly.  In  the  majority 
of  cases  there  is  a  period  during  which  there  is  headache  of  a  very 
severe  character,  vomiting  which  is  quite  independent  of  the  ingestion 
of  food,  chills  and  rigors  of  varying  severity,  slight  rise  of  temperature 
with  rapid  pulse  and  pronounced  degree  of  prostration.  During  this 
period  the  diagnosis  of  brain  abscess  usually  is  not  made,  this  may  last 
for  one  or  several  days  and  is  followed  by  the  period  during  which 
characteristic  symptoms  of  cerebral  abscess  appear.  There  is  some 
pain  in  the  head  and  slight  tenderness  on  percussion  over  the  site  of 
the  disease.  There  develops  a  peculiar  mental  state  as  shown  by 
slow  cerebration  during  which  the  patient  is  asked  a  question  and  then 
waits  a  considerable  interval  before  he  answers,  but  then  usually 
answers  correctly.  There  is  also  a  lack  of  sustained  attention  during 
which  he  may  ask  for  a  drink  of  water  and  then  fall  asleep  before  he 
receives  it,  or  he  may  commence  a  long  answer  to  some  question  only 
to  lapse  into  slumber  before  he  finishes  it.  He  often  lacks  the  power 
to  use  his  strength,  not  so  much  from  any  physical  weakness  as  from 
a  loss  of  will-power  to  exert  it.  As  time  goes  on  his  mental  obscuration 
increases.  His  temperature  is  normal  or  even  subnormal,  his  pulse 
is  slow  and  full.  Respirations  are  slow.  There  is  apt  to  be  a  pro- 
nounced degree  of  constipation  and  a  complete  loss  of  appetite.  The 
optic  neuritis  is  a  constant  and  pronounced  symptom  and  as  the 
disease  progresses  the  patient  becomes  emaciated. 

Course.— If  left  untreated  the  case  may  terminate  in  several  ways. 
Death  may  result  gradually,  preceded  by  stupor  and  coma  with  signs 
of  brain  compression  or  with  symptoms  of  acute  leptomeningitis,  or 


DISEASES  OF  THE  BRAIN  363 

suddenly,  due  to  the  rupture  of  the  abscess  into  the  ventricle.  McEwen 
divides  cases  of  brain  abscess  into  those  which  develop  with  complete 
latency,  with  subacute  evolution,  those  similar  to  brain  tumors  and 
those  of  the  remittent  type  in  which  there  are  exacerbations  of  severe 
symptoms  followed  by  periods  during  which  the  symptoms  are  much 
ameliorated,  if  not  entirely  absent. 

Treatment. — When  abscess  of  the  brain  is  suspected,  the  skull 
should  be  opened  by  a  large  trephine  or  by  the  osteoplastic  method, 
the  dura  incised,  and  the  surface  of  the  cortex  examined  for  bulging, 
softening,  or  absence  of  pulsation.  A  grooved  director  should  next 
be  introduced  in  several  directions,  and  when  pus  is  reached  the 
opening  should  be  enlarged  by  introducing  a  pair  of  closed  dressing- 
forceps  and  withdrawing  them  with  the  blades  slightly  separated. 
The  cavity,  if  large,  may  then  be  explored  by  the  finger,  irrigated  with 
salt  solution,  packed  lightly  with  gauze,  and  the  wound  partly  closed. 
During  these  manipulations  the  subdural  space,  unless  it  is  closed  by 
adhesions,  is  sure  to  be  contaminated  with  the  pus,  and  should  be 
drained  by  pledgets  of  gauze  introduced  between  the  dura  and  sur- 
rounding cortex.  The  pus  of  chronic,  long-standing  brain  abscesses, 
however,  is  likely  to  be  sterile.  The  subsequent  treatment  should 
consist  in  cleanliness  and  frequent  gentle  packing  of  the  cavity  until 
it  fills  with  granulations. 

Sinus  Thrombosis. — Sinus  thrombosis  may  arise  in  the  marasmic 
state  of  the  very  young  or  very  old  or  in  those  patients  debilitated 
from  disease,  as  typhoid  fever,  or  it  may  be  the  result  of  trauma; 
but  the  most  frequent  form  is  that  due  to  a  septic  inflammation  of 
the  walls  of  a  sinus,  the  infection  usually  being  brought  to  the  sinus 
by  a  neighboring  osteomyelitis,  or  septic  thrombosis  of  one  or  more 
small  tributary  veins.  The  sinus  becomes  filled  with  a  thrombus, 
which  also  becomes  infected,  and  later  may  soften,  disintegrate,  and 
be  carried  by  the  circulation  to  any  part  of  the  body,  giving  rise  to 
metastatic  abscesses  and  pyemia.  While  any  of  the  cerebral  sinuses 
may  become  infected,  the  one  most  commonly  diseased  is  the  lateral 
sinus  from  extension  of  a  septic  process  of  the  middle  ear  through  the 
mastoid  cells  to  its  sigmoid  portion.  Next  in  frequency  comes  the 
cavernous  sinus,  from  direct  infection  from  the  sphenoidal  cells  or  from 
a  septic  thrombosis  of  the  veins  about  the  orbit  or  forehead.  Throm- 
bosis of  the  longitudinal  sinus  or  of  the  petrosal  are  rare. 

Symptoms. — The  symptoms  of  infective  thrombosis  of  the  lateral 
sinus  are  usually  preceded  by  a  history  of  an  acute  exacerbation  of  an 
old  middle-ear  disease  with  tenderness  over  the  mastoid  and  fever. 
Following  this  there  is  a  severe  constant  localized  pain,  with  marked 
elevation  of  temperature  and  a  rapid,  feeble  pulse.  The  fever  is 
marked  by  notable  remissions;  there  may  be  chills  and  sweats.  If 
the  process  extends  to  the  jugular  vein,  there  will  be  pain  and  induration 
over  the  region  of  the  upper  part  of  the  jugular  in  the  neck.  If  the 
cavernous  sinus  is  involved,  there  will  be  exophthalmos  and  chemosis, 


364         INJURIES  AXD   DISEASES  OF  HEAD  AXD  BRAIX 

with  congestion  of  the  lids  and  dilatation  of  the  retinal  veins.  In 
advanced  stages  of  sinus  thrombosis  evidences  of  involvement  of  the 
cranial  nerves  may  be  present.  Thus  in  involvement  of  the  lateral 
sinus  and  jugular  vein,  hoarseness,  dysphagia,  or  paresis  of  the  muscles 
supplied  by  the  spinal  accessory;  in  cavernous  thrombosis,  paralysis 
of  the  ocular  muscles,  hyperesthesia  over  the  distribution  of  the 
trigeminus,  or  choked  disk  may  be  present.  At  a  later  period  in 
the  disease  evidences  of  metastatic  accidents  manifest  themselves, 
and  the  patient  gradually  succumbs  to  general  septic  infection. 

Treatment. — This  should  be  undertaken  at  the  earliest  possible 
moment,  and  should  consist  in  freely  exposing  the  mastoid  region 
by  a  curved  incision  back  of  the  ear,  supplemented  if  necessary  by 
a  horizontal  incision  at  right  angles  to  the  first.  The  mastoid  antrum 
and  cells  should  be  freely  opened  by  a  chisel  or  rongeur  forceps,  and 
the  -inns  located  and  opened.  The  clots  should  be  gently  removed 
first  from  the  direction  of  the  torcula  and  then  from  the  jugular 
extremity  until  blood  flows.  The  -inns  should  then  be  irrigated  with 
salt  solution,  and  packed  with  sterile  gauze.  If  the  thrombus  extends 
well  into  the  jugular  vein,  this  should  be  ligated  below  the  disease, 
opened,  and  if  possible  irrigated  from  above.  The  wound  should  then 
be  partly  closed,  ample  provision  being  made  for  drainage  of  the 
tympanum  and  mastoid  antrum. 

Thrombosis  of  any  of  the  other  cerebral  sinuses,  if  considerable, 
may  be  treated  in  the  same  manner;  but,  as  a  rule,  the  symptoms 
are  obscure  and  the  condition  remains  unrecognized  until  it  is  beyond 
the  help  of  the  surgeon. 

As  stated  above,  in  many  of  these  cases  of  intracranial  sepsis  the 
surgeon  is  unable  to  make  an  exact  diagnosis,  as  two  or  more  of  these 
processes  may  be  present  at  the  same  time.  In  such  cases  the  necessary 
operations  are  in  the  nature  of  exploratory  procedures,  the  sub- 
sequent steps  of  the  operation  depending  upon  the  pathologic  lesions 
found. 

Hydrocephalus. — Hydrocephalus  is  an  abnormal  collection  of  fluid 
within  the  cranial  cavity.  In  external  hydrocephalus  the  fluid  is 
in  the  subdural  space,  in  internal  hydrocephalus  the  fluid  is  in  the 
ventricular  cavity.  The  condition  may  be  congenital  or  acquired. 
It  is,  however,  surgically  important  only  in  infancy  and  childhood. 
In  the  congenital  variety,  which  is  usually  internal,  the  ventricular 
distention  may  be  due  to  some  obstruction  in  the  aqueduct  of  Sylvius 
which  prevents  the  fluid  secreted  in  the  lateral  ventricles  from  passing 
downward  through  the  fourth  ventricle  and  the  foramen  of  Magendie 
into  the  subarachnoid  space,  although  dishing,  who  has  recently 
given  the  subject  much  attention,  found  no  such  obstruction  in  the 
majority  of  his  cases.  In  these  cases  the  accumulation  of  fluid  may 
be  enormous,  distending  the  cranial  cavity  to  five  or  six  times  its 
natural  size  (Fig.  ISO).  The  bones  are  widely  separated,  the  brain  is 
converted  into  a  thin-walled  sac,  and  all  surface-markings  are  obliter- 


DISEASES  OF  THE  BRAIN 


365 


ated.  The  child  shows  little  or  no  mental  activity,  and  death  often 
occurs  at  an  early  period.  In  less  severe  cases,  when  life  is  prolonged, 
the  child  may  be  an  idiot  or  imbecile.  The  acquired  variety  may  be 
due  to  some  new  growth  pressing  on  the  iter  or  the  veins  of  Galen,  or  to 
meningitis.  The  external  form  is  not  infrequently  associated  with 
chronic  internal  pachymeningitis. 

Treatment. — The  treatment  of  this  condition  is  unsatisfactory. 
External  pressure  is  of  no  avail.  Ventricular  tapping  gives  only 
temporary  relief,  and  permanent  external  drainage  is  practically 
always  followed  by  sepsis.  Draining  the  ventricular  cavity  into  the 
subdural  space  would  seem  to  be  the  rational  plan  of  treatment,  and 
if  it  could  be  accomplished  at  an  early  period  before  permanent  press- 
ure-effects are  produced  it  might  prove  to  be  of  value.  Two  or  three 
successful  cases  have  been  reported.  The  author  lias  on  three  occasions 
established  an  opening  into  the  ven- 
tricular cavity  through  the  tentorial 
surface  of  the  occipital  lobe,  and 
introduced  an  inverted  T-shaped 
drain  of  folded  rubber  tissue,  the 
horizontal  arm  resting  on  the  tentor- 
ium and  the  vertical  portion  pass- 
ing through  the  opening  into  the 
ventricle.  Access  to  the  part  was 
obtained  through  an  omega-shaped 
osteoplastic  flap,  which  was  after- 
ward replaced  and  tightly  sutured 
without  drainage.  One  patient 
lived  six  weeks  with  marked  im- 
provement, the  head  diminishing 
some  three  inches  in  circumference; 
the  others  died  as  the  result  of 
operation.  Alfred  S.  Taylor  has 
recently  reported  a  series  of   cases 

resulting  from  epidemic  cerebrospinal  meningitis  in  which  he  drained 
the  ventricles  into  the  subdural  space  over  the  convexity,  using  sev- 
eral strands  of  catgut  instead  of  the  rubber  tissue. 

Cushing,  in  the  cases  in  which  a  communication  can  be  demon- 
strated to  exist  between  the  ventricles  and  the  subarachnoid  space, 
advises  the  establishment  of  a  communication  between  the  spinal 
arachnoid  space  and  the  retroperitoneal  areolar  tissue  by  means  of 
a  trephine  opening  through  the  body  of  the  fifth  lumbar  vertebra 
and  the  introduction  of  a  silver  canula. 

Meningocele ;  Encephalocele ;  Hydro-encephalocele—  Meningocele 
is  a  protrusion  of  one  or  more  of  the  cerebral  membranes  through  a 
congenital  aperture  in  the  skull.  This  usually  occurs  in  the  median 
line  of  the  occipital  or  frontal  region,  the  protrusion  appearing  as  a 
large  or  small  oval  cystic  tumor  beneath  the  scalp  which  increases  in 


Fig.  180.— Hydrocephalus. 


366         INJURIES  AND  DISEASES  OF  HEAD  AND  BRAIN 

size  and  tension  on  coughing  or  crying.     Fluctuation  is  generally 
present  and  the  contents  may  be  diminished  by  pressure  (Fig.  181). 

Encephalocele  is  the  protrusion  of  a  portion  of  brain  tissue  within  a 
meningocele. 

Hydro-encephalocele  is  an  encephalocele  which  contains  also  within 
the  brain  substance  a  cavity  communicating  with  the  ventricle. 

These  conditions  are  all  due  to  congenital  defects  and  in  most 
instances  the  tumors  are  present  at  birth.  The  larger  and  perhaps 
the  most  frequently  observed  instances  are  those  belonging  to  the 
hydro-encephalocele  class. 

Treatment. — The  treatment  of  these  conditions  is  very  unsatisfactory 
as  a  rule.  Extirpation  of  the  sac,  with  ligature  of  the  pedicle  and 
closure  of  the  wound,  is  to  be  advised  in  meningocele  and  encephalocele 
when  the  brain  substance  can  be  reduced.  The  insertion  of  a  celluloid 
plate,  between  the  scalp  and  the  surrounding  bone,  is  to  be  recom- 
mended to  prevent  recurrence.  Removal  of  a  protruding  portion 
of  the  brain  substance  may  be  attempted.  When  no  operative 
measures   seem   advisable   the    child    should    wear    some    protecting 

apparatus  to  avoid  rupture  from 
blows  or  falls. 

Hernia  Cerebri. — Hernia  cere- 
bri is  the  protrusion  of  a  portion  of 
the  brain  through  an  opening 
in  the  skull.  This  condition  is 
frequently  observed  after  com- 
pound fractures  and  operations 
on  the  brain  when  marked  intra- 
Fig.  181.— Cerebral  meningocele.  cranial  pressure  is  present. 

The  protrusion  may  occur  be- 
neath the  healed  scar  of  such  an  injury,  or  it  may  occur  before 
closure  of  the  wound.  In  the  latter  case  the  condition  is  perhaps 
more  accurately  described  as  prolapse  of  the  brain.  The  condition  is 
extremely  troublesome,  as  the  protruding  portion  consists  of  a  fungat- 
ing  bleeding  mass,  which  may  readily  become  infected  and  is  a  source 
of  great  annoyance  to  the  patient. 

Treatment. — The  treatment  should  consist  in  an  attempt  to  cover  the 
mass  with  sound  skin,  or,  better,  with  a  bone  flap.  To  accomplish 
this,  excision  of  the  protruding  mass  may  be  necessary.  The  operation 
is  a  difficult  one,  and  is  attended  with  considerable  danger.  When 
the  skin  is  unbroken  the  hernia  may  be  treated  by  an  external  protect- 
ing plate  of  celluloid  or  metal,  or  such  a  plate  may  after  reduction 
be  inserted  between  the  scalp  and  the  bone. 

Traumatic  or  Focal  Epilepsy. — When,  following  a  severe  trauma  of 
the  head,  presumably  associated  with  some  injury  to  the  brain  or  its 
membranes,  a  previously  healthy  individual  becomes  epileptic,  the 
condition  is  spoken  of  as  a  traumatic  epilepsy.  When,  in  a  given  case 
of  epilepsy,  the  seizure  invariably  begins  in  a  certain  group  of  muscles 


DISEASES  OF  THE  BRAIN  367 

and  always  progresses  in  a  regular  order  which  corresponds  to  the  areas 
in  the  motor  region  of  the  brain  cortex  which  would  be  affected  by  an 
irritation  spreading  from  a  given  point,  the  condition  is  called  focal 
or  Jacksonian  epilepsy. 

In  these  cases  the  cause  of  the  epileptic  attack  is  probably  a  local 
one  situated  at  the  point  of  injury  or  in  that  part  of  the  motor  area  of 
the  cortex  which  corresponds  with  the  group  of  muscles  first  attacked 
by  the  seizure.  In  these  cases  exploratory  operations  are  indicated, 
and  removable  lesions  are  frequently  found  which  fully  account  for 
the  symptoms.  The  lesion  may  be  a  depressed  spicule  of  bone,  an 
adhesion  between  the  dura  and  pia,  a  dural,  pial,  or  cortical  hemor- 
rhage, or  a  cyst  resulting  from  such  a  hemorrhage,  a  patch  of  meningeal 
thickening,  a  small  cprtical  abscess  or  tumor. 

Treatment. — The  treatment  of  these  cases  should  consist  in  an 
exploratory  osteoplastic  resection  of  the  skull,  with  relief  of  pressure 
from  any  cause,  separation  of  adhesions,  removal  of  a  foreign  body 
or  solid  tumor,  evacuation  of  a  cyst  or  cortical  abscess,  or  in  some 
instances  complete  excision  of  a  hopelessly  diseased  cortical  area. 

Prognosis. — The  prognosis  should  be  guarded,  for  although  the 
original  cause  of  the  disease  may  be  removed,  the  "epileptic  habit" 
is  often  established,  which  will  require  a  continuance  of  the  ordinary 
medical  treatment  for  some  time  after  recovery  from  the  operation. 

It  has  been  suggested  by  Jonnesco  to  remove  the  two  upper  cervical 
ganglia  of  the  sympathetic  for  cure  of  the  ordinary  idiopathic  epilepsy. 
The  operation,  which  is  described  in  Chapter  XI,  has  been  followed 
by  improvement  in  a  few  cases,  but  the  number  of  failures  is  so  greatly 
in  excess  of  the  successes  that  the  operation  has  fallen  into  dis- 
favor. 

Traumatic  Cephalalgia.  —  Severe  persistent  headache  following  a 
cranial  trauma  and  accurately  localized  on  the  supposed  seat  of  injury 
is  due,  not  infrequently,  to  some  local  lesion  similar  to  those  producing 
epileptic  seizures.  The  probability  of  such  an  association  is  accen- 
tuated if  pressure  over  the  scar  or  seat  of  injury  is  painful  and  acts  as 
an  exciting  cause  of  the  headache.  In  these  cases  exploratory  opera- 
tion is  to  be  advised  if  the  symptoms  are  of  such  a  character  as  to 
justify  the  comparatively  slight  risk  of  such  a  procedure. 

The  Cerebral  Injuries  of  the  Newborn. — The  terms  infantile  cere- 
bral palsy,  congenital  spastic  paralysis,  etc.,  are  generally  employed 
to  indicate  physical  defects  which  are  the  direct  result  of  injuries 
to  the  brain  occurring  during  parturition.  Idiocy,  imbecility,  and 
epilepsy  are  also  not  infrequently  due  to  these  injuries.  In  the  great 
majority  of  instances  the  lesions  in  these  cases  are  due  to  hemorrhages, 
lacerations  of  the  meninges  or  of  the  cerebral  substance,  to  edema, 
to  an  increased  intracranial  tension,  and  to  the  frequently  associated 
asphyxia. 

The  investigations  of  Gushing,  Carmichael,  and  others  have  shown 
that  in  many,  if  not  the  majority  of  these  cases,  the  primary  lesions 


368         INJURIES  AND  DISEASES  OF  HEM)  AND  BRAIN 

are  located  over  the  convexity  of  the  cerebrum  and  near  the  superior 
longitudinal  sinus. 

It  is  obvious  that  if  these  cases  can  be  successfully  operated  upon 
during  the  first  few  days  after  birth,  the  clots  removed,  and  pressure 
relieved,  many  of  the  disastrous  secondary  lesions  can  be  avoided. 
The  subject  is  a  new  one,  and  comparatively  little  attention  has  been 
paid  to  it  by  surgeons,  but  the  brilliant  success  which  has  been  achieved 
by  ( 'ushing  in  several  such  instances  lead  to  the  belief  that  much  may 
be  accomplished  by  early  operation  in  these  otherwise  hopeless  cases. 

In  operating  upon  these  cases  the  same  methods  should  be  employed 
as  in  adults,  great  care,  however,  being  necessary  in  the  administration 
of  the  anesthetic  and  in  the  measures  employed  to  maintain  the  body 
temperature  and  to  combat  shock. 

Among  the  other  causes  of  idiocy  and  imbecility  some  authors 
include  premature  ossification  of  the  sutures  and  fontanelles,  causing 
intracranial  pressure  from  a  failure  of  the  skull  to  expand  to  meet  the 
requirements  of  the  growing  brain.  In  these  cases  linear  craniectomy 
has  been  advised.  The  operation  consists  in  making  one  or  more 
incisions  through  the  skull  parallel  with  the  sagittal  suture  and  extend- 
ing from  the  frontal  region  to  the  occiput.  Supplementary  incisions 
are  sometimes  made  at  an  oblique  or  right  angle  to  these,  which  allow 
a  very  considerable  amount  of  expansion  of  the  skull.  As  there  is  little 
or  no  reason  to  believe  that  the  mental  defects  are  in  any  way  dependent 
on  the  early  closure  of  the  sutures,  the  operation  has  little  to  recommend 
it,  and  lias  been  generally  abandoned  by  surgeons. 

TUMORS  OF  THE  BRAIN. 

The  tumors  which  occur  in  the  brain  or  grow  from  its  membranes 
are,  in  the  order  of  frequency:  syphilitic  or  tuberculous  granulomata, 
endotheliomata,  gliomata,  sarcomata,  angiomata,  psammomata, 
fibromata,  neuromata,  and  cysts. 

Symptoms. — These  depend  entirely  upon  the  situation  of  the  tumor 
and  the  structures  pressed  upon  by  its  growth.  It  not  infrequently 
happens  that  tumors  even  of  considerable  size  may  exist  for  months 
or  years  in  one  of  the  silent  areas  of  the  brain  without  producing 
symptoms  which  lead  one  even  to  suspect  intracranial  disease.  On 
the  other  hand,  comparatively  small  growths  in  other  regions  may 
produce  a  train  of  symptoms  of  the  most  painful  and  distressing  char- 
acter, making  life  unbearable  and  driving  patients  to  suicide.  The 
four  cardinal  symptoms  of  brain  tumor  are  headache,  vomiting,  vertigo, 
and  optic  neuritis.  While  all  of  these  symptoms  are  usually  present 
at  some  period  in  the  history  of  most  cerebral  tumors,  they  are  by  no 
means  always  early  symptoms,  and  are  certainly  not  pathognomonic 
of  new  growths,  for  they  may  occur  in  any  intracranial  disease  which 
produces  ventricular  distention  or  slowly  developing  pressure  from 
other  causes.     These  four  symptoms  may  be  called  the  general  symp- 


TUMORS  OF  THE  BRAIN  369 

toms  of  tumor,  and  are  usually  present  whatever  its  location.  In 
addition  to  the  changes  in  the  disk,  Harvey  Cushing  has  recently 
called  attention  to  another  important  and  very  early  ocular  sign  of 
intracranial  pressure,  which  is  frequently  the  first  positive  indication 
of  cerebral  tumor.  This  sign  consists  in  the  demonstration  of  a  change 
in  the  color  fields,  with  irregularity  and  overlapping  of  the  various 
color  areas.  The  general  blood-pressure  is  not  increased  in  the  majority 
of  the  cases. 

Many  other  symptoms  may  be  present,  due  to  the  location  of  the 
growth,  and  may  be  spoken  of  as  the  special  or  localizing  symptoms, 
for  by  their  presence  or  absence  conclusions  may  often  be  drawn 
regarding  the  probable  situation  of  the  growth.  Of  the  special  symp- 
toms which  may  be 'produced  by  the  growth  of  a  cerebral  tumor, 
the  most  important  are  those  caused  by  the  irritation  or  paralysis  of 
certain  well-known  cortical  centres  or  the  origins  of  the  cranial  nerves. 
Thus  in  tumors  of  the  motor  area  we  have  Jacksonian  epilepsy,  mani- 
fested in  the  muscles  of  the  face  or  extremities  on  the  side  of  the  body 
opposite  to  the  lesion ;  or  if  the  pressure  is  greater,  paralysis  of  one  or 
more  groups  of  these  muscles  will  result.  In  tumors  of  the  superior 
parietal  convolution,  astereognosis  is  observed.  In  tumors  of  the 
prefrontal  region  there  may  be  no  localizing  signs,  but  mental  disturb- 
ances are  of  frequent  occurrence,  especially  if  the  lesion  is  in  the  left 
hemisphere  (Phelps).  In  growths  affecting  the  posterior  extremity 
of  the  third  left  frontal  convolution  motor  aphasia  is  present.  In 
tumors  of  the  occipital  lobe  and  of  the  posterior  portion  of  the  parietal 
lobe,  visual  disturbances  are  common,  while  in  the  temporosphenoidal 
lobe,  especially  on  the  left  side,  a  tumor  may  give  rise  to  deafness  and 
impairment  of  the  senses  of  taste  and  smell. 

Tumors  at  the  base  of  the  brain  may  produce  hemiplegia,  hemi- 
anopsia, hemianesthesia,  with  paralysis  of  one  or  more  of  the  cranial 
nerves.  Tumors  of  the  hypophysis  give  rise  to  bitemporal  hemian- 
opsia, severe  headache,  symptoms  of  acromegaly,  and  loss  of  sexual 
power.  Tumors  of  the  cerebellopontine  angle,  the  so-called  acoustic 
neuromata,  cause  a  distressing  tinnitus,  unilateral  deafness,  and 
later,  give  rise  to  paralysis  of  the  fifth,  sixth,  and  seventh  nerves. 
Tumors  of  the  cerebellum,  if  near  the  worm,  produce  marked  ataxia 
and  staggering  gait;  the  patients,  when  asked  to  walk  a  straight  line, 
will  more  frequently  stagger  away  from  the  side  on  which  the  tumor 
is  located,  than  toward  it.  Cerebellar  tumors  also  give  rise  to  a  rapidly 
advancing  choked  disk  and  nystagmus.  Nerve  deafness  when  present 
may  be  regarded  as  a  reliable  indication  of  the  situation  of  the  tumor. 
It  occurs  on  the  same  side  as  the  lesion,  while  the  other  cranial  nerve 
palsies  occasionally  present  in  cerebellar  tumor  may  occur  on  either 
side.  Tumors  of  the  medulla  are  generally  rapidly  fatal,  the  early 
symptoms  being  cardiac  and  respiratory  disturbances  with  dysphagia 
and  cranial  nerve  palsies. 

Of  all  the  symptoms  of  cerebral  tumor,  pain  and  vomiting  are  the 
24 


370  INJURIES  AND   DISEASES  OF  HEM)  AND  BRAIN 

most  distressing.  The  pain  is  seldom  definitely  localized,  but  it  is 
progressive  in  character,  eventually  becoming  so  severe  as  entirely 
in  prevent  sleep,  and,  with  the  uncontrollable  vomiting,  produces  a 
condition  of  extreme  exhaustion. 

Occasionally  the  headache  is  more  localized,  but  too  much  reliance 
should  not  be  placed  on  this  symptom  in  locating  the  lesion,  for  the 
reason  that  prefrontal  growths  often  are  accompanied  by  severe 
occipital  pain,  and  cerebellar  tumors  not  infrequently  give  rise  to 
pain  located  chiefly  in  the  frontal  region. 

There  is  little  to  help  us  in  determining  the  nature  of  the  growth. 
A  well-marked  history  of  syphilis,  and  the  fact  that  the  early  cerebral 
symptoms  were  of  a  transitory  nature,  and  varied  in  character,  would 
indicate  the  probability  of  a  syphilitic  gumma;  while  a  tuberculous 
history  and  the  evidences  of  tuberculosis  in  other  organs  would  favor 
the  belief  that  the  growth  was  of  tuberculous  nature.  The  occurrence 
of  cerebral  symptoms  following  malignant  disease  in  other  organs 
would  suggest  the  probability  of  a  meta>tasis  of  malignant  character. 
Rapid  development  of  symptoms  and  evidences  of  pressure  would 
suggest  a  rapidly  growing  sarcoma  rather  than  a  more  slowly  develop- 
ing glioma  or  fibroneuroma.  Psammomata  occur  chiefly  within  the 
ventricles  or  the  region  of  the  lateral  recesses  and  the  flocculus. 
Hydatid  cysts  of  the  dura  and  tentorium  have  been  reported.  Cystic 
formations  caused  by  blood-clots  are  of  fairly  frequent  occurrence, 
but  as  they  show  no  tendency  to  grow  they  rarely  produce  severe 
symptoms. 

Prognosis. — The  prognosis  in  non-syphilitic  tumors  of  the  brain  is 
grave.  Unless  relief  is  afforded  by  surgical  means  the  termination 
is  invariably  fatal. 

Treatment. — Syphilitic  gummata  of  the  brain  should  be  treated 
by  salvarsan,  increasing  doses  of  potassium  iodide  combined  with 
mercury,  administered  by  the  mouth,  inunction,  or  hypodermic 
injection.  The  iodide  should  be  given  in  large  doses,  as  improvement 
frequently  does  not  manifest  itself  until  from  100  to  300  grains  are 
given  daily.  Tumors  of  a  doubtful  nature  should  also  receive  the 
benefit  of  this  treatment  for  purposes  of  diagnosis.  While  the  vast 
majority  of  tumors  of  the  brain  are  inaccessible  for  surgical  treatment, 
in  a  few  instances  (about  7  per  cent.)  tumors  are  located  in  region>  in 
which  they  may  be  successfully  exposed  and  extirpated.  Whenever 
there  is  a  reasonable  probability  that  a  non-syphilitic  tumor  is  located 
at  or  near  the  surface  of  the  cerebrum  or  cerebellum  the  region  should 
be  exposed  by  an  osteoplastic  resection  of  the  skull,  the  dura  opened, 
and  the  surface  of  the  brain  examined.  Absence  of  pulsation  and  an 
induration  appreciated  by  palpation  suggest  the  possibility  of  a  sub- 
cortical growth.  Solid  tumors  may  be  recognized  by  their  appearance 
and  density,  angiomata  by  their  pulsation  and  compressibility,  cysts 
by  the  sense  of  fluctuation.  Gliomata  are  often  difficult  of  recognition 
on  account  of  their  soft  consistence  and  the  fact  that  when  situated 


OPERATIONS  ON  THE  BRAIN  371 

beneath  the  surface  they  present  an  appearance  only  of  an  enlarged 
convolution  and  have  no  sharply  defined  borders.  Exploratory 
puncture  of  the  brain  by  means  of  a  director  or  blunt-pointed  probe 
will  occasionally  reveal  the  presence  of  a  tumor  at  some  distance  from 
the  surface.  Incision  through  the  cortex  and  palpation  of  the  deeper 
parts  with  the  finger  enabled  the  writer  on  one  occasion  to  detect  a 
hard  cerebellar  tumor  situated  about  one  inch  from  the  surface.  When 
located,  the  tumor  can  generally  be  removed  by  enucleation  by  the 
finger,  a  sharp  spoon,  or  a  flat  periosteum  elevator.  Hemorrhage 
should  be  checked  by  ligation  of  the  pial  vessels  and  the  liberal  use 
of  hydrogen  peroxide  in  the  cavity,  followed  by  packing  with  sterile 
gauze.  If  no  hemorrhage  follows  removal  of  the  tumor,  only  a  small 
rubber  tissue  drain  should  be  left  in  the  wound,  the  bone  flap  returned 
and  sutured  in  place.  If  the  wound  is  packed,  the  flap  should  not  be 
sutured  until  the  packing  is  removed,  or  a  window  should  be  cut  in  the 
bone  to  allow  of  its  subsequent  removal.  While  these  procedures  are 
accompanied  by  grave  dangers,  the  risk  is  justifiable,  for  the  disease 
if  left  to  itself  is  invariably  fatal. 

When  the  tumor  cannot  be  accurately  located  or  when  its  complete 
extirpation  is  impossible,  removal  of  a  large  piece  of  the  skull  with  an 
opening  in  the  dura  will  often  relieve  the  intracranial  pressure  and 
bring  about  a  marked  amelioration  in  the  pain,  vomiting,  optic  neuritis, 
and  other  distressing  symptoms.  A  favorite  site  for  such  decompres- 
sion operations  is,  as  suggested  by  Gushing,  in  the  temporal  region, 
as  the  resulting  disturbances  are  less  than  when  more  important 
areas  are  crowded  through  the  cranial  defect.  Whenever  the  opening 
in  the  skull  is  near  the  motor  area,  paresis  or  paralysis  is  apt  to  follow 
the  operation  from  pressure  of  the  cortex  on  the  bony  margin  of  the 
opening. 

OPERATIONS  ON  THE  BRAIN. 

As  the  special  procedures  which  are  indicated  in  the  surgical  treat- 
ment of  the  different  brain-lesions  have  already  been  described,  it 
remains  only  necessary  to  describe  the  methods  of  opening  the  skull 
and  gaining  access  to  the  various  regions  of  the  cranial  cavity. 

Trephining.  Craniotomy. — While  the  term  "trephining"  literally 
refers  to  the  act  of  cutting  out  a  circular  piece  of  the  skull  with  a 
trephine  (Fig.  182),  it  has  by  common  usage  been  employed  to 
indicate  any  surgical  method  of  opening  the  cranial  cavity. 

Before  proceeding  to  open  the  skull,  the  patient's  head  should  be 
shaved  and  the  chief  fissures  and  other  landmarks  laid  out  and  per- 
manently marked  on  the  scalp  by  needle-scratches.  After  this  is  done 
the  entire  scalp  should  be  carefully  prepared  for  an  aseptic  operation. 

After  the  patient  is  anesthetized  the  region  to  be  explored  is  deter- 
mined and  the  centre  of  the  proposed  opening  indicated  by  the  mark 
of  an  awl  driven  through  the  soft  parts  into  the  bone.  If  the  trephine 
is  to  be  used,  a  generous  curved  incision  should  be  made  through 


372  INJURIES  AND  DISEASES  OF  HEAD  AND  BRAIN 

the  tissues  of  the  scalp  down  to  the  bone,  the  soft  parts  retracted,  and 
the  awl-mark  located.  The  central  pin  of  the  trephine  should  be 
placed  over  this  mark  and  the  trephine  rotated  backward  and  forward 
until  a  distinct  groove  is  cut  in  the  bone.  The  pin  is  then  drawn 
upward  and  the  sawing  continued  until  the  inner  table  is  perforated 
at  one  or  more  points.  This  is  indicated  both  by  the  sensation 
imparted  to  the  hand  and  by  exploration  of  the  cut  with  the  flat  end 
of  a  probe  or  wooden  toothpick.  The  button  of  bone  can  be  removed 
by  lateral  manipulation  of  the  trephine  or  by  a  narrow  periosteum 
elevator.  After  the  button  of  bone  is  removed,  the  opening  in  the 
skull  may  be  enlarged  to  any  extent  by  rongeur  forceps. 


Fig.  182.— Trephine. 


Osteoplastic  Craniotomy.— When  the  osteoplastic  method  is  em- 
ployed, an  omega-shaped  incision  is  made,  the  base  of  which  will  be  so 
situated  as  to  contain  the  bloodvessels  and  nerves  supplying  the  part 
(Fig.  183).  This  incision  is  carried  to  the  bone,  but  without  retracting 
the  soft  parts  any  more  than  is  necessary  to  expose  freely  the  curved 
line  of  the  bare* bone  at  the  bottom  of  the  incision.  The  bone  is 
divided  by  the  Gigli  saw  (Fig.  184)  through  a  series  of  small  trephme- 
openings;  or  one  of  the  various  forms  of  the  surgical  engine  may  be 
employed.  When  the  bone  is  sufficiently  loosened,  it  is  carefully 
raised* by  an  elevator,  the  soft  parts  remaining  attached,  and  is  broken 
off  at  the  base  of  the  omega.  As  the  size  of  the  opening  which  may 
be  made  by  this  method  is  unlimited,  large  areas  of  cerebral  cortex 
can  be  examined,  and,  after  the  necessary  procedures  have  been  carried 
out,  the  bone  may  be  replaced,  the  soft- parts  sutured,  and  no  defect 


OPERATIONS  ON   THE  BRAIN 


373 


in  the  skull  remains.  This  method  in  skilful  hands  is  quicker  than 
that  by  the  use  of  the  trephine;  it  gives  far  greater  exposure  and  leaves 
no  weak  spot  for  the  subsequent  development  of  a  hernia. 

After  the  skull  has  been  opened  by  either  of  these  methods  the  dura 
may  be  divided  by  a  curved  incision,  which  is  best  made  by  a  fine 
pair  of  curved  scissors.  The  further  steps  of  the  operation  are  deter- 
mined by  the  character  of  the  lesion,  and  have  already  been  described. 
In  closing  such  a  wound  the  dura  should  be  united  with  catgut,  the 
scalp  by  silkworm  gut,  a  large  dressing  of  sterile  gauze  and  cotton 
should  be  applied  and  held  in  place  by  a  starch  or  dextrin  bandage. 

To  expose  the  cerebellum  Cushing  employs  a  T-shaped  incision 
through  the  soft  parts,  laying  bare  both  halves  of  the  occipital  bone. 
He  then  removes  enough  bone  to  expose  thoroughly  both  hemispheres. 


Fig.  183. — Osteoplastic   resection  of  skull, 
after  Wagner. 


Fig.  184. — Gigli  saw. 


By  partly  dislocating  one  lobe,  he  is  able  to  retract  the  other  sufficiently 
to  gain  access  to  the  cerebello-pontine  recess  without  lacerating  the 
cortex  or  producing  dangerous  pressure  on  the  medulla. 

Cushing's  temporal  decompression  operation  consists  in  exposing 
the  bone  by  means  of  a  curved  incision  above  the  zygoma,  separating, 
but  not  dividing,  the  fibres  of  the  temporal  muscle,  and  removing  a 
sufficient  area  of  bone  and  dura  to  give  relief  of  the  intracranial  press- 
ure; after  which  the  soft  parts  are  accurately  replaced  and  sutured. 
In  cases  of  extreme  tension  the  operation  may  be  performed  on  both 
sides.  For  additional  data  on  the  technic  of  cerebral  operations 
and  for  a  description  of  the  rarer  procedures,  as  the  approach  to  the 
hypophysis,  etc.,  the  reader  is  referred  to  the  recent  monographs  of 
Horsley,  Hartley,  and  Cushing. 


CHAPTER  XVI. 
INJURIES  AND  DISEASES  OF  THE  SPINE. 

ANATOMY  OF  THE  SPINAL  CORD. 

The  spinal  canal  is  the  space  enclosed  between  the  bodies,  trans- 
verse processes  and  laminae  of  the  vertebrae  and  the  ligaments  which 
bind  them  together.  It  is  always  larger  than  the  spinal  cord.  It 
is  lined  by  a  layer  of  fat  which  is  interposed  between  the  bony  ligamen- 
tous canal  and  the  sheath  of  dura  mater.  Between  the  dura  mater  and 
the  pia  mater  which  is  closely  applied  to  the  spinal  cord  there  is  a 
considerable  space  which  is  filled  with  cerebrospinal  fluid.  On  either 
side  there  extends  from  the  dura  mater  to  the  pia  mater  a  series  of 
processes  composed  of  the  arachnoid,  the  ligamenta  dentata  which 
supports  the  spinal  cord  in  the  canal. 

The  spinal  cord  begins  above  just  below  the  decussation  of  the 
pyramids  opposite  the  atlas  and  extends  down  to  opposite  the  second 
lumbar  vertebra,  where  it  tapers  off  into  the  filum  terminale.  The 
spinal  nerves  have  an  intraspinal  course  which  increases  from  above 
downward.  The  spinal  cord  is  considered  as  composed  of  different 
segments,  one  for  each  pair  of  spinal  nerves.  The  relationship  of 
these  segments  to  the  vertebral  spines  is  shown  in  Fig.  185.  The  sen- 
sory distribution  of  each  segment  is  shown  in  Plate  XIII.  The  sen- 
sory distribution  of  peripheral  nerves  is  shown  in  Fig.  1SG.  Within  the 
white  matter  of  the  spinal  cord  are  arranged  the  different  fibres  which 
convey  impulses  from  the  periphery  to  the  central  nervous  system 
and  from  the  central  nervous  system  to  the  periphery. 

In  considering  lesions  of  the  cord  one  should  bear  in  mind  that  the 
terms  used,  although  the  same  as  those  employed  in  lesions  of  the  brain 
do  not  have  the  same  significance.  Compression  of  the  cord,  for 
example,  refers  to  the  effect  of  local  pressure,  as  we  cannot  distinguish 
any  general  pressure. 

INJURIES  AND  DISEASES  OF  THE  SPINE  AND  CORD. 

Fractures  of  the  Spine. — Fracture  of  the  spine  is  so  often  accom- 
panied by  a  dislocation  that  the  two  forms  of  injury  had  best  be 
considered  together.  Injuries  of  this  kind  generally  result  from  a  fall 
or  some  severe  crushing  force  which  violently  bends  the  vertebral 
column.  Parts  of  one  or  more  of  the  vertebrae  may  be  fractured  by  a 
direct  blow,  as  the  spinous  process  or  vertebral  arches,  and  occasionally 


PLATE   XIII 


Areas  of  Anesthesia   upon    the  Body  after  Lesions  in  the 
Various  Segments  of  the  Spinal  Cord. 

The  segments  of  the  eord  are  numbered:  C  I  to  VIII,  D  I  to  XII,  L  I  to  V, 
S  1  to  5,  and  these  numbers  are  placed  on  the  region  of  the  skin  supplied 
by  the  sensory  nerves  of  the  corresponding  segment.      (Starr.) 


ANATOMY  OF  THE  SPINE  AND  CORD 


375 


.X.  to  rectus  lateralis 

J2-to  rectus  antic,  miliar 

.  Anastomosis  with  hypoglossal 

.Anastomosis  with  pm  umogastric 
_X.  to  rectus  antic.major. 
.JIT,  tu  mastoid  region. 
.Great  auricular  n. 
-Transverse  cervical  n. 
X.  tu  Trapezius,  Ana.  Scap.  and  Rhomboid. 


JSupra-  < 

.Phrenic  n. 

N.  to  levator  aug.  scap. 

If.  to  rhomboid 

Subscapular  n. 

.Subclavicular  n. 


N.  to pectoralis  major. 


.Circumflex  n. 

Musculo-cutaneous  n. 
Median  n. 
Radial  n. 

Ulnar  n. 

Internal  cutaneous  n. 

Small  internal  cutaneous  n. 


Ilio-hypogastric  n. 
llio-inguinal  n. 


.External  cutaneous  n. 
.Genito-crural  n. 


Anterior  crural  a. 
Obturator  n. 


\    to  tphim  ter  ani 

Coccygeal  n. 


Superior  gluteal  n. 


X.  to  piriformis 

X.  to  gemellus  super. 


X.  to  gemellus  infer. 
X.  to  quadrutus 

Small  sciatic  n. 
Sciatic  n. 


Fig.  185. — The  relation  of  the  segments  of  the  spinal  cord  and  their  nerve  roots  to 
the  bodies  and  spines  of  the  vertebrae.  (Dejerine  et  Thomas,  Mai.  d.  1.  Moelle  Epiniere, 
Paris,  1902.) 


Fig.  186. — The  distribution  of  sensory  nerves  in  the  skin.  (After  Flower.)  The 
areas  of  the  skin  supplied  by  the  cutaneous  nerves  are  shown  in  finely  dotted  outline. 
The  circles  on  the  trunk  show  areas  occasionally  anesthetic  in  hysteria.  The  lines 
across  the  limbs  at  ankle,  knee  and  thigh,  wrist,  elbow  and  shoulder  show  the  upper 
limits  of  anesthesia  in  multiple  neuritis  of  varying  degrees  of  severity. 


ANATOMY  OF  THE  SPINE  AND  CORD 


377 


muscular  action  may  play  a  minor  part  in  the  injury.  Pure  disloca- 
tions are  rare,  five-sixths  of  the  cases  occurring  in  the  cervical  region. 
(Chapter  XXX.)  Fractures  are  more  commonly  met  with  in  the  cervi- 
cal and  dorsal  regions,  the  most  frequent  point  of  injury  being  the  fifth 
and  sixth  cervical,  the  last  dorsal,  and  first  lumbar.  The  line  of  fracture, 
when  the  body  is  involved,  may  be  in  any  direction,  but  is  generally 
transverse  or  oblique  (Fig.  187).  Comminution  may  occur,  and 
occasionally  impaction  takes  place,  giving  rise  to  angular  deformity 
without  displacement.  In  by  far  the  greater  number  of  these  injuries 
there  are  both  fracture  and  dislocation,  a  condition  which  has  been 
termed  fracture-dislocation.  While  fracture  of  a  portion  of  a  vertebra 
may  occur  without  producing  any  injury  of  the  cord,  in  the  great 
majority  of  cases  these  injuries  result  in  a  temporary  or  permanent 


Fig.  187. — Transverse  fracture  of 
vertebra.     (Stimson.) 


Fig.  188. — Displacement  of  the  vertebrae  causing 
compression  of  the  spinal  cord. 


displacement  which  gives  rise  to  a  more  or  less  serious  cord  lesion 
(Fig.  188).  It  occasionally  happens  that  the  immediate  displace- 
ment which  has  produced  a  permanent  transverse  lesion  of  the  cord 
has  been  spontaneously  reduced  before  the  patient  is  seen  by  the 
surgeon. 

The  cord  lesion  may  be  simply  a  contusion  from  the  driving  inward 
of  a  fragment  of  a  fractured  arch,  compression  from  displaced  bone, 
or  hemorrhage  which  may  be  extradural,  in  the  subdural  space,  or 
in  the  anterior  horn  of  the  gray  matter  of  the  cord  (hematomyelia) ; 
or  the  cord  may  be  crushed  and  its  functions  permanently  impaired 
by  the  deformity  which  follows  the  severe  forms  of  this  injury. 

Symptoms. — The  symptoms  of  fracture  of  the  spine  are  of  two 
kinds:  those  due  to  injury  to  the  spinal  column,  and  those  due  to 
injury  of  the  cord.     The  former  are  deformity,  localized  tenderness, 


378  INJURIES  AND  DISEASES  OF   THE  SPINE 

pain  on  movement  of  the  trunk,  and  crepitus;  the  latter  are  sensory 
and  motor  paralyses,  retention  of  urine,  involuntary  movements  of 
the  bowels,  priapism,  the  formation  of  bed-sores,  variation  in  the 
reflexes,  and  occasionally  hyperpyrexia. 

In  fracture  without  dislocation  there  may  be  no  deformity  present; 
generally,  however,  there  is  a  prominence  of  one  or  more  of  the  spinous 
processes,  which  may  amount  to  a  well-recognized  angular  deformity. 
In  fracture  of  the  spinous  process  there  may  be  a  depression  over  the 
injured  process.  Localized  pain  and  tenderness  are  practically  always 
present,  but  crepitus  is  frequently  absent. 

Fracture  or  dislocation  of  the  atlas  and  axis  is  very  rare,  and  is 
almost  always  fatal  either  immediately  or  after  a  few  days.  The 
symptoms  of  fracture  or  dislocation  of  the  upper  four  or  five  cervical 
vertebra?  are  more  or  less  complete  paralysis  of  motion  and  sensation 
below  the  injury,  rigidity  of  the  neck,  localized  pain,  embarrassment 
of  the  respiration,  priapism,  and  hyperpyrexia.  There  may  be  no 
recognizable  deformity. 

Fracture  or  dislocation  of  the  lower  cervical  and  upper  dorsal  presents 
noticeable  deformity;  the  paraplegia  is  generally  complete  to  the 
region  of  the  diaphragm,  irregular  above  this  point.  Paralysis  of  the 
upper  extremity  may  develop  immediately  or  after  several  hours  or 
days.  There  is  absence  of  thoracic  respiration,  and  paralytic  myosis 
may  be  present.  It  is  generally  rapidly  fatal  if  the  phrenics  are 
involved;  more  slowly  if  below  that  point. 

Fracture-dislocations  of  the  dorsal  and  lumbar  region  are  less  rapidly 
fatal,  and  when  below  the  eleventh  dorsal  the  paralysis  may  be  incom- 
plete owing  to  the  rarity  of  marked  displacement  in  this  region,  and 
consequently  less  complete  injury  to  the  cord,  and  also  to  the  fact  that 
below  the  second  lumbar  vertebra  the  canal  contains  only  the  cauda 
equina,  a  bundle  of  nerve  trunks.  Partial  or  complete  recovery 
from  the  paralysis  may  take  place  after  these  fractures. 

Not  infrequently  after  injuries  to  the  spinal  column  there  is  complete 
paraplegia,  with  paralysis  of  the  bladder  and  rectum  and  the  rapid 
formation  of  bed-sores,  thermo-anesthesia,  but  without  loss  of  tactile 
sensation.  In  these  cases  the  lesion  is  not  a  crushing  injury  of  the  cord, 
but  a  hemorrhage  into  the  anterior  horns  of  the  gray  matter  (hemato- 
myelia).  If  no  other  lesion  exists,  recovery  from  this  condition  may 
be  confidently  expected  in  from  six  to  twelve  weeks. 

Treatment. — In  the  treatment  of  fracture  or  dislocation  of  the 
spine  the  surgeon  should  be  guided  by  the  probable  condition  of  the 
cord.  In  all  cases  in  which  there  is  reason  to  believe  that  the  injury 
to  the  cord  is  not  a  crushing  one,  attempts  should  be  made  to  reduce 
the  displacement  if  any  exists,  and  to  bring  about  a  union  of  the  fracture 
by  fixation.  This  is  sometimes  effected  in  the  cervical  region  by 
extension  and  counter-extension,  aided  by  manipulation  at  the  seat 
of  injury,  and  should  be  followed,  if  successful,  by  the  application  of  a 
plaster  collar  and  head  bandage.     In  fractures  of  the  dorsal  and  lumbar 


ANATOMY  OF  THE  SPINE  AND  CORD 


379 


regions  reduction  is  often  aided  by  suspension.  In  the  majority  of 
instances,  however,  reduction  of  a  fracture-dislocation  can  only  be 
accomplished  by  open  operation.  In  all  cases,  whether  reduction  is 
accomplished  or  not,  fixation  by  a  plaster  jacket  gives  comfort  to  the 
patient  and  favors  union. 

The  question  of  operative  intervention  in  injuries  of  this  kind  is 
one  upon  which  there  is  considerable  difference  of  opinion. 

In  crushing  injuries  of  the  cord  restoration  of  function  never  occurs, 
so  that  relief  of  pressure  by  operation  could  be  of  no  possible  value. 
On  the  other  hand,  hematomyelia,  in  which  the  prognosis  is  favorable, 


Fig.  189. — Intradural  hemorrhage  due  to  fracture-dislocation  which  had  been 
spontaneously  reduced. 


recovers  as  well  without  as  with  operation.  This  leaves  only  the 
cases  in  which  the  symptoms  are  due  to  pressure  from  depressed 
bone  or  hemorrhage,  upon  which  operation  offers  any  chance  for 
improvement. 

In  these  cases  laminectomy  may  reveal  the  cause  of  the  pressure, 
which  can  sometimes  be  removed.  It  should  be  remembered,  however, 
that  hemorrhage  may  exist  with  a  crushing  injury  of  the  cord,  which 
upon  inspection  through  an  opening  in  the  dura  shows  no  macroscopic 
sign  of  injury.  Fig.  189  represents  such  a  condition,  in  which  the 
writer  believed  that  complete  recovery  would  probably  follow  removal 


380  INJURIES  AND  DISEASES  OF   THE  SPINE 

of  the  clot,  whereas  upon  microscopic  examination  the  cord  was  found 
to  be  wholly  disintegrated  by  a  crushing  injury. 

In  an  organ  as  deeply  seated  and  as  well  protected  as  the  spinal 
cord  it  is  difficult  to  understand  how  it  can  be  structurally  injured 
by  a  blow  or  other  trauma  applied  to  the  back  which  does  not  produce 
a  fracture  or  dislocation  of  the  bony  canal.  That  such  is  the  case, 
however,  is  evidenced  by  an  abundance  of  pathologic  material. 

Concussion,  Contusion,  and  Multiple  Punctate  Hemorrhage  of 
the  Cord. — Much  controversy  has  arisen  regarding  these  three  con- 
ditions, the  existence  of  which  as  distinct  pathologic  processes,  unasso- 
ciated  with  other  graver  lesions,  and  recognizable  during  life,  is  open 
to  question.  While  we  are  not  prepared  to  deny  that  distinctly  spinal 
symptoms,  as  pain,  numbness,  more  or  less  complete  paralysis  of 
sensation  and  motion,  relaxation  of  the  sphincters,  etc.,  may  be  present 
for  a  short  period  following  spinal  traumata,  which  do  not  exhibit 
evidences  of  grave  and  more  permanent  lesions,  and  may  perhaps  be 
conveniently  classed  under  the  term  concussion  of  the  spine,  that  such 
symptoms  may  persist  for  any  considerable  period  of  time  has  not  been 
proved.  These  cases  should  be  clearly  differentiated  from  those  of 
traumatic  neurasthenia  and  hysteria,  in  which  the  only  spinal  symptoms 
present  are  purely  subjective  in  character,  and  the  chief  disturbances 
are  mental  and  emotional  rather  than  physical. 

Spinal  Hemorrhage. — By  spinal  hemorrhage  is  meant  a  hemorrhage 
of  sufficient  extent  to  produce  pressure-syinptoms,  which  may  occur 
as  a  result  of  trauma,  within  the  bony  canal  of  the  spine. 

Extradural  and  Subdural  Hemorrhages. — Extradural  and  Subdural 
hemorrhages  are  described  in  most  works  on  surgery.  They  are 
present  in  practically  all  cases  of  severe  injury  to  the  spine,  and  by 
their  presence  and  the  pressure  they  exert  may  modify  to  a  certain 
extent  the  symptoms  present  in  such  cases.  If  they  ever  occur 
unassociated  with  fracture  or  dislocation  or  without  injury  to  the  cord, 
they  are  surgically  unimportant,  for  they  cannot  be  recognized  during 
life  (Bailey). 

Hematomyelia ;  Intramedullary  Hemorrhage. — This  condition,  as 
accurately  described  by  Bailey,  is  of  fairly  frequent  occurrence.  It 
is  chiefly  confined  to  the  cervical  region,  and  is  generally  caused  by 
sudden  forcible  flexion  or  extension  of  the  vertebral  column,  without 
fracture,  such  as  results  from  diving  in  shallow  water  and  striking 
the  head  violently  against  the  bottom. 

The  hemorrhage  occurs  chiefly  in  the  anterior  horn  of  the  gray 
matter,  and  may  extend  upward  or  downward  for  a  considerable 
distance.  Occasionally  it  spreads  to  both  sides  of  the  cord  and 
involves  the  posterior  horns. 

Symptoms. — The  symptoms  are  often  complete  muscular  paralysis 
below  the  lesion  with  varying  sensory  disturbances,  of  which  loss  of 
sensibility  to  heat  and  cold,  and  to  pain,  with  normal  tactile  sensibility, 
are  the  most  characteristic.  Paralysis  of  the  bladder  and  rectum 
may  be  present  and  bed-sores  occasionally  develop. 


AX  ATOMY  OF   THE  SPIXE   AND   CORD 


:;m 


Prognosis. — The  prognosis  depends  upon  the  extent  of  the  hemor- 
rhage. In  general  it  may  be  said  that  in  an  ordinary  ease  of  hemato- 
myelia  partial  or  complete  recovery  may  be  expected  within  two  or 
three  months. 

Treatment. — The  treatment  of  spinal  hemorrhage  consists  in  rest 
and  careful  nursing,  to  avoid  bed-sores  and  cystitis. 

Transverse,  Crushing  Lesions  of  the  Cord  from  Fracture,  Dislocation, 
or  Direct  Wound. — This  is  the  pathologic  condition  commonly  present 
in  cases  of  "broken  back."  The  injury  is  caused  in  these  cases  by 
the  crushing  force  of  a  displaced  vertebral  segment,  which,  however, 
frequently  springs  back  into  place  before  the  patient  is  seen  by  the 
surgeon,  leaving  no  obvious  sign  of  dislocation  or  fracture  with 
displacement. 

Symptoms. — The  symptoms  of  a  complete  transverse  lesion  of  the 
cord  are  total  paralysis  of  sensation  which  is  symmetrical  on  the  two 


Fig.  190. — Thorburn's  position  in  fracture  of  spine. 


sides  of  the  body  and  motion  below  the  point  of  injury  with  immediate 
absence  or  diminution  of  reflexes  (these,  however,  may  return  at  a 
later  period  or  become  exaggerated).  The  muscles  supplied  by  the 
injured  segment  atrophy  and  present  the  reaction  of  degeneration. 
The  muscles  supplied  by  the  segments  below  the  injury  subsequently 
contract,  become  rigid  and  show  normal  electrical  reactions.  Trans- 
verse lesions  of  the  cord  at  or  above  the  fourth  cervical  segment  are 
rapidly  fatal  from  paralysis  of  the  muscles  of  respiration.  If  the 
lesion  lies  below  the  origin  of  the  phrenic  nerves  life  may  be  somewhat 
prolonged.  In  fractures  in  the  neighborhood  of  the  fifth  and  sixth 
segments  Th  orb  urn  describes  a  characteristic  attitude:  The  patient 
lies  with  the  arms  abducted  and  rotated  outward,  the  elbows  flexed, 
and  the  forearm  supinated.  There  is  total  paralysis  of  sensation 
and  motion  below  the  point  of  injury,  with  priapism,  paralysis  of  the 
rectum  and  bladder,  and  the  formation  of  bed-sores.     Respiration 


382  INJURIES  AND  DISEASES  OF   THE  SPINE 

is  embarrassed  and  asphyxia  may  occur  from  inability  of  the  patient 
to  expel  mucus  from  the  trachea  and  bronchi.  In  lesions  of  the 
lower  dorsal  and  lumbar  regions  the  prognosis  as  to  life  is  better, 
death  generally  taking  place  from  sepsis  due  to  bed-sores  or  infection 
of  the  bladder  and  kidneys. 

The  evidence  is  very  slight  that  in  a  total  transverse  lesion  the 
cord  is  ever  regenerated  to  a  sufficient  extent  to  result  in  a  restoration 
of  function. 

Treatment. — The  treatment  in  cases  of  total  transverse  lesions  of 
the  cord  should  consist  in  careful  nursing  to  avoid  bed-sores  and 
infection  of  the  bladder.  Pressure  over  the  sacral  region  should  be 
avoided  by  rubber  rings,  and  the  parts  should  be  kept  scrupulously 
clean.  The  position  of  the  patient  should  be  frequently  changed,  and 
all  pressure-points  frequently  bathed  with  alcohol.  Regular  aseptic 
catheterization  is  necessary.  The  application  of  a  plaster  jacket  is 
advisable  to  keep  the  parts  at  rest. 

Incomplete  Crushing  Lesions  of  the  Cord. — These  may  occur  in 
fractures  of  the  vertebral  arches  and  in  partial  luxations.  The  symp- 
toms are  incomplete  paralysis  of  sensation  and  motion,  the  distribution 
of  the  anesthesia  being  asymmetric.  In  place  of  complete  loss  of 
subjective  symptoms  there  is  pain  of  a  sharp  lancinating  character, 
and  other  sensations  as  formications  and  tingling.  The  reflexes  are  not 
completely  lost.  In  these  cases,  which  are  rare,  exploratory  operations 
are  indicated  for  the  detection  and  removal  of  depressed  fragments 
of  bone  and  to  relieve  pressure  on  the  cord. 

Injuries  to  the  Cauda  Equina. — Below  the  first  lumbar  vertebra 
fractures  of  the  spine  injure  only  the  cauda  equina,  and  while  sensory 
and  motor  paralysis,  absence  of  reflexes  and  trophic  disturbances 
follow  these  injuries  and  closely  simulate  injuries  of  the  cord,  several 
points  of  difference  may  be  enumerated. 

Cord  injuries,  as  a  rule,  are  not  associated  with  pain.  Injuries 
of  the  cauda  give  rise  often  to  severe  pain,  especially  in  the  hyper- 
esthetic  zone  just  above  the  paralyzed  area.  In  injuries  of  the  cauda 
the  anesthesia  is  irregular  in  distribution  and  generally  less  in  extent 
than  in  cord  lesions.  The  cauda,  being  made  up  of  peripheral  nerves, 
is  capable  of  repair  after  injury,  and  for  that  reason  recovery  more 
frequently  occurs  than  after  crushing  injuries  of  the  cord. 

The  tissues  of  the  cauda  are  more  resistant  to  injury  than  the 
cord ;  a  given  trauma  will  therefore  produce  more  complete  destruction 
of  the  latter  than  of  the  former  structure. 

In  spinal  injuries  above  the  second  lumbar  vertebra  both  cord  and 
cauda  may  be  injured,  evidenced  by  the  occurrence  of  sensory  disturb- 
ances one  or  two  segments  above  the  level  of  the  cord  injury.  In 
these  cases  evidence  of  severe  injury  to  the  nerve  roots  renders  the 
prognosis  more  grave,  as  it  is  probable  that  the  injuring  force  was 
sufficiently  severe  to  produce  a  crushing  lesion  of  the  cord. 


SPINAL  TUMORS  383 

OPERATIVE  TREATMENT  OF  SPINAL  INJURIES. 

As  sufficient  regeneration  to  insure  a  return  of  function  never 
occurs  after  complete  transverse  crushing  lesions  of  the  cord,  operation 
is  of  no  value. 

As  the  symptoms  of  hematomyelia  frequently  disappear  spontane- 
ously, and  as  the  lesion  cannot  be  influenced  by  operative  interven- 
tion, operation  is  distinctly  contra-indicated.  This  leaves  only  the 
incomplete  injuries  of  the  cord  and  the  lesions  of  the  cauda  equina, 
which  are  likely  to  be  benefited  by  operation. 

If,  therefore,  an  accurate  diagnosis  could  be  arrived  at  in  all  cases 
at  the  time  of  injury,  the  operative  indications  would  be  clear.  Unfor- 
tunately, however,  this  is  not  the  case,  as  Mixter,  Munro,  and  others 
have  reported  cases  recovering  after  operation  when  the  symptoms 
clearly  pointed  to  a  crushing  lesion  of  the  cord. 

Most  surgeons  now  agree  with  Walton,  McCosh,  and  Keen,  who 
advocate  an  exploratory  laminectomy  after  a  reasonable  period  of 
observation  in  all  cases  of  doubt  regarding  the  character  and  extent 
of  a  given  cord  injury. 

SPINAL  TUMORS. 

Tumors  causing  pressure  on  the  spinal  cord  may  grow  from  the 
bony  spine,  from  the  spinal  membranes,  or  from  the  cord  itself. 
Tumors  of  the  bone  are  generally  malignant  in  character  and  are 
most  frequently  secondary  to  deposits  elsewhere.  Exostoses  and 
chondromata  have  been  reported.  Of  the  meningeal  tumors  which 
form  the  most  important  class,  sarcomata  and  endotheliomata  are  the 
most  common,  while  myxomata,  fibromata,  lipomata,  and  psammomata 
are  occasionally  encountered. 

Sarcomata  and  gliomata  occur  in  the  cord,  but  are,  as  a  rule, 
inoperable. 

Of  the  infective  granulomata,  tuberculous  and  syphilitic  are  of 
frequent  occurrence,  especially  the  former.  These  may  produce 
the  same  symptoms  as  the  genuine  new  growths.  The  majority 
of  meningeal  tumors  develop  on  the  posterior  or  lateral  aspect  of  the 
cord,  which  accounts  for  the  early  occurrence  of  sensory  disturbances. 

Symptoms. — These,  as  a  rule,  are  classified  as  root  symptoms  and 
pressure  signs.  Irritation  the  of  sensory  nerve  roots  by  a  growing 
tumor  gives  rise  to  neuralgic  pains,  increased  by  motion;  various 
paresthesias,  and  later  anesthesia.  These  may  persist  for  months 
or  years  before  motor  symptoms  occur.  At  a  later  period  there 
occur  muscular  spasms,  paresis,  and  finally  paralysis,  with  the  reaction 
of  degeneration  and  atrophy. 

As  a  rule,  the  pain  diminishes  with  the  advent  of  the  motor  paralysis, 
and  in  the  later  stages  may  be  absent.  The  reflexes  at  first  are  exagger- 
ated, later  diminished,  and  finally  lost.  Trophic  disturbances  occur, 
and  the  patient  finally  becomes  bed-ridden  and  helpless. 


384  INJURIES  AND  DISEASES  OF   THE  SPINE 

In  the  early  stages  the  symptoms  may  be  unilateral;  later,  as  the 
cord  is  more  completely  compressed,  a  total  paraplegia  develops. 

Regarding  the  situation  of  the  lesion  in  the  spinal  canal,  the  most 
reliable  data  can  be  obtained  from  the  early  symptoms  of  sensory 
root  irritation.  These,  with  the  later  distribution  of  the  cutaneous 
anesthesia  and  the  upper  limit  of  the  motor  paralysis,  will  generally 
enable  one  to  determine  the  segment  of  cord  involved.1 

Prognosis. — Unlike  the  behavior  of  sarcomata  in  other  parts  of  the 
body,  meningeal  sarcomata  grow  slowly,  do  not  infiltrate  the  surround- 
ing tissues,  and  rarely  recur,  if  removed  at  a  comparatively  early  stage. 
For  this  reason  the  prognosis  in  meningeal  tumors  is  favorable  if  the 
diagnosis  can  be  made  and  the  growth  removed  before  the  cord  has 
been  compressed  to  such  a  degree  as  to  destroy  the  conductivity  of 
its  fibres.  Infiltrating  tumors  of  the  cord  are  obviously  beyond  the 
possibility  of  surgical  relief. 


Fig.  191. — Spina  bifida  with  myelomeningocele. 

Spinal  tumors  unless  relieved  by  surgical  measures,  in  the  great 
majority  of  instances,  end  fatally. 

Treatment. — The  treatment  in  all  but  the  secondary  or  late  malignant 
cases  should  be  early  exploratory  laminectomy  and  removal,  when  this 
is  possible.  As  Elsberg  has  pointed  out,  this  may  be  done  in  two 
stages.  In  the  first  step  the  tumor  is  exposed  and  possibly  the  mem- 
branes over  it  are  incised;  it  is  then  allowed  to  rest  for  several  days, 
during  which  time  the  tumor  is  extruded  and  may  be  readily  removed 
with  little  or  no  injury  to  the  cord. 

Spina  Bifida. — Spina  bifida  is  a  congenital  defect  in  the  spinal 
column  caused  by  a  non-union  of  the  laminse  of  one  or  more  vertebral 
segments,  usually  in  the  lumbar  or  sacral  regions.  Several  varieties 
exist : 

1  For  a  more  detailed  description  of  the  facts  in  spinal  localization,  the  reader  is 
referred  to  the  tables  and  plates  in  Starr's  Organic  Nervous  Diseases. 


SPINAL  TUMORS  385 

Spina  bifida  occulta,  in  which  the  spinal  defect  exists  alone.  The 
region  of  the  defect  is  apt  to  be  covered  with  hair.  It  is  often 
associated  with  perforating  ulcer  of  the  foot. 

Meningocele. — A  hernia  of  the  spinal  membrane  forming  a  cystic 
protrusion  covered  with  epidermis. 

Meningomyelocele. — A  meningocele  having  the  flattened  spinal  cord 
on  its  posterior  wall,  the  commonest  variety. 

Syringomyelocele. — The  meninges  are  defective;  the  protruding 
cyst  is  composed  of  the  tissues  of  the  cord  dilated  by  a  collection  of 
fluid  in  the  closed  central  canal.     Very  rare. 

Myelocele. — An  imperfect  union  of  the  medullary  folds.  The 
central  canal  is  open  and  the  medullary  folds  are  spread  out  on  either 
side  and  are  continuous  with  the  skin.  The  medullary  portion  is  of  a 
bright  red  color  and  highly  vascular.  Children  with  myelocele  die 
a  few  days  after  birth  from  constant  leakage  of  the  cerebrospinal  fluid . 

Moore,  who  collected  statistics  from  the  literature  of  the  operative 
cases  prior  to  1905,  states  that  23  per  cent,  occurred  in  the  sacral 
region,  34  per  cent,  in  the  lumbar,  29  per  cent,  at  the  lumbosacral 
junction,  and  14  per  cent,  in  the  cervical  and  dorsal  regions. 

The  condition  is  often  associated  with  other  congenital  defects, 
as  club-foot  and  hydrocephalus;  and  in  a  fair  proportion  of  the  cases 
more  or  less  paralysis  of  the  sphincters  and  lower  extremities  is  present. 

Prognosis. — The  prognosis  of  this  condition,  if  left  to  itself,  is 
grave,  the  severer  types  dying  shortly  after  birth,  and  many  of  the 
cases  of  meningocele  and  meningomyelocele  dying  from  rupture  of  the 
sac  and  the  subsequent  development  of  meningitis. 

Treatment. — Spina  bifida  occulta,  if  well  covered  by  healthy  skin, 
needs  no  treatment.  Small  meningoceles  without  symptoms  may  be 
treated  by  a  protective  dressing  to  guard  against  rupture. 

The  presence  of  hydrocephalus,  extensive  paralysis,  or  other  marked 
deformities  would  be  a  contra-indication  to  operative  treatment. 

Meningoceles  and  meningomyeloceles  without  paralysis  should  be 
treated  by  operation.  The  sac  should  be  exposed  by  an  elliptical 
incision  and  freely  opened.  Any  nerve-fibres  which  do  not  end  in 
the  sac  should  be  dissected  out  and  returned  to  the  spinal  canal. 

The  redundant  sac  should  then  be  excised  to  a  point  near  the  neck, 
and  the  dura  firmly  closed  by  ligating  the  neck  or  by  two  or  more 
rows  of  catgut  sutures.  Lovett  then  recommends  the  formation  of 
two  rectangular  flaps  of  muscle  and  fascia  with  their  bases  toward  the 
median  line.  These  are  inverted  and  firmly  united  over  the  stump 
of  the  miningocele  by  chromic  gut  sutures,  after  which  the  skin  is 
united  with  silk  or  silkworm  gut. 

The  operative  mortality  is  about  33  per  cent.,  and  the  secondary 
mortality,  after  one  or  more  years,  about  30  per  cent.  Permanent 
recovery  may  be  expected  in  about  one-third  of  the  casts. 


25 


:N',  ix. JURIES  AXD  DISEASES  OF   THE  SPJXE 


OPERATIONS  ON  THE  SPINE. 

Lumbar  Puncture. — Lumbar  puncture  is  practised  for  the  relief  of 
intracranial  pressure  or  for  purposes  of  diagnosis.  When  practised 
for  relief  of  intracranial  pressure  it  must  be  carefully  employed  in 
brain  tumors  because  of  the  danger,  especially  in  the  case  of  tumors 
of  the  posterior  fossa,  that  on  the  relief  of  pressure  the  medulla  is 
crowded  against  the  foramen  magnum  causing  instant  death.  Locate 
the  spinous  process  of  the  fourth  lumbar  vertebra,  and  after  thorough 
aseptic  preparation  of  the  part,  introduce  an  aspirating-needle  at  a  point 
a  half-inch  to  the  left  of  the  spine  and  carry  it  obliquely  upward  and 
inward  between  the  laminae  until  the  dura  is  punctured.  This  will  be 
indicated  by  a  flow  of  cerebrospinal  fluid  through  the  trocar.  After 
sufficient  fluid  is  withdrawn,  remove  the  needle  and  close  the  wound 
with  collodion  or  sterile  zinc  oxide  plaster. 

Laminectomy. — Laminectomy,  or  opening  the  spinal  canal,  is  per- 
formed for  exploratory  purposes  in  fractures,  dislocations,  and  other 
injuries,  and  for  the  removal  of  tumors. 

Place  the  patient  face  downward  on  the  operating-table,  and  after 
thorough  preparation  of  the  operative  field  make  an  eight-inch  vertical 
incision  in  the  median  line  over  the  spine.  Divide  the  soft  parts 
down  to  the  laminae  on  either  side  of  the  spinous  processes  and  retract 
the  edges  of  the  incision.  Control  the  hemorrhage  by  gauze  pressure 
Next  remove  the  spines  by  heavy  bone-forceps,  and  with  small  curved 
bone-forceps  divide  the  laminae  on  either  side  as  near  the  transverse 
processes  as  possible,  and  remove  the  intervening  part  of  the  arch. 
Several  laminae  should,  if  necessary,  be  removed  to  give  a  satisfactory 
exposure  of  the  cord.  If  it  is  necessary  to  open  the  dura,  it  should  be 
incised  in  the  median  line  and  subsequently  closed  with  a  continuous 
catgut  suture. 

Closure  of  a  laminectomy  wound  should  be  effected  with  deeply 
placed  silkworm-gut  sutures,  a  rubber  tissue  drain  being  left  in  the 
inferior  angle  of  the  wound.  After  an  aseptic  dressing  is  placed  over 
the  wound  a  plaster-of-Paris  corset  should  be  applied  and  the  patient 
placed  on  his  back  in  bed. 


CHAPTER  XVII. 

INJURIES  AND  DISEASES  OF  THE  FACE  AND  NECK, 
ORAL,  NASAL,  AND  PHARYNGEAL  CAVITIES. 

INJURIES  OF  THE  FACE  AND  NECK. 

Contusions. — Contusions  of  the  face  are  of  frequent  occurrence,  and 
often  produce  great  disfigurement  from  the  ecchymosis  and  edema, 
of  which  the  ordinary  "black  eye"  is  the  type.  Cold  applications 
are  usually  all  that  is  necessary  in  the  way  of  treatment. 

Contusions  of  the  neck  occasionally  result  in  serious  injury  of  the 
nerve  trunks,  especially  the  brachial  plexus,  giving  rise  to  a  more  or 
less  complete  paralysis  of  the  upper  extremity.  Blows  on  the  neck 
and  angle  of  the  jaw  give  rise  to  a  severe  degree  of  shock  and  sometimes 
to  intracranial  hemorrhage. 

Wounds  of  the  Face  and  Neck. — In  wounds  of  the  face  great  care 
should  be  taken  to  avoid  subsequent  deformity.  Marginal  necrosis 
should  be  prevented  by  avoiding  too  much  tension  of  the  sutures. 
If  the  edges  of  the  wound  are  widely  separated,  one  or  two  retention 
sutures  should  be  passed  at  some  distance  from  the  edges  of  the  cut, 
and  the  margins  in  this  way  brought  together.  The  skin  should  be 
carefully  approximated  and  united  by  a  number  of  fine  silk  sutures, 
which  should  be  removed  as  early  as  possible  to  prevent  scarring. 
If  in  wounds  of  the  face,  branches  of  the  seventh  nerve  are  divided, 
the  ends  should  be  united  with  fine  catgut. 

If  Stenson's  duct  is  cut,  the  ends  should  be  accurately  united  with 
fine  catgut,  or  the  proximal  extremity  should  be  drawn  outward,  passed 
through  an  incision  in  the  mucous  membrane  of  the  cheek,  secured 
by  fine  silk  sutures,  and  the  external  wound  closed.  In  case  a  fistula 
results,  this  may  often  be  cured  by  wearing  a  soft  probe  in  the  duct 
introduced  through  the  oral  orifice  and  carried  beyond  the  fistula 
to  the  gland,  the  outer  portion  of  the  probe  to  be  curved  about  the 
angle  of  the  mouth  and  secured  to  the  cheek  by  adhesive  plaster.  In 
old  cases  in  which  the  distal  portion  of  the  duct  is  obliterated  a  new 
one  may  be  made  by  piercing  the  cheek  with  a  trocar  from  the  fistulous 
opening  inward  and  forward  to  a  point  near  the  original  termination 
of  the  duct.  This  may  be  kept  open  by  a  seton  or  the  probe  introduced 
as  above.  Freshening  and  union  of  the  cutaneous  wound  by  sutures 
or  contractile  collodion,  while  the  probe  is  in  place,  will  be  required. 

Superficial  wounds  of  the  neck  differ  in  no  way  from  cutaneous 
wounds  elsewhere.     They  should  be  throughly  disinfected  and  sutured. 


388  INJURIES  AND  DISEASES  OF  FACE  AND  NECK 

In  more  extensive  wounds  penetrating  the  deep  fascia,  important 
structures  may  be  wounded,  requiring  special  treatment.  In  wounds 
of  the  larger  vessels  the  hemorrhage  may  he  temporarily  controlled 
by  pressure,  but  an  immediate  operation  should  be  undertaken  to 
expose  the  vessels  thoroughly,  which  should  be  securely  ligated  above 
and  below  the  point  of  injury,  after  which  the  wound  should  be 
carefully  disinfected  and  closed  with  sutures. 

Wounds  of  the  pharynx,  larynx,  or  trachea,  often  seen  after  attempts 
at  suicide  by  "cutting  the  throat,"  are  dangerous  not  so  much  on 
account  of  the  immediate  injury  as  by  their  remote  results.  Thus  in 
transverse  wounds  above  the  hyoid  bone  the  severed  tongue  or  epiglottis 
may  drop  backward  into  the  rima  glottidis  and  cause  suffocation; 
in  wounds  below  the  hyoid  or  those  severing  the  thyroid  cartilages  an 
edema  of  the  glottis  may  suddenly  appear  and  cause  death  from 
suffocation  before  help  can  arrive;  while  in  wounds  of  the  trachea 
the  blood  issuing  from  the  neighboring  veins  or  injured  thyroid  gland 
may  be  aspirated  and  asphyxiate  the  patient.  In  all  of  these  cases 
death  from  pneumonia  may  occur  at  a  later  period  from  the  inhalation 
of  septic  material.  The  treatment  of  these  cases  should  consist  in 
arresting  all  hemorrhage,  carefully  uniting  the  divided  structures,  and 
performing  a  tracheotomy  below  the  injured  area.  In  wounds  invok- 
ing the  esophagus  the  walls  of  this  passage  should  be  closed  tightly 
with  two  layers  of  suture  and  the  superficial  parts  brought  together 
with  provision  for  adequate  drainage. 

Wounds  of  the  anterior  portion  of  the  neck  rarely  cause  injury  to 
the  large  nerve  trunks  (pneumogastric,  sympathetic,  glossopharyngeal, 
and  phrenic),  on  account  of  the  deep  and  protected  situation  of  these 
structures.  Wounds  in  the  lateral  portions  of  the  neck,  however, 
frequently  cause  injury  to  one  or  more  branches  of  the  brachial  plexus. 
Whenever  a  nerve  trunk  is  known  to  have  been  divided,  the  ends 
should  be  secured  and  united  by  suture. 


INFLAMMATORY  DISEASES  OF  THE  FACE  AND  NECK. 

Facial  Erysipelas. — An  acute,  rapidly  spreading  inflammation  of 
the  skin  and  subcutaneous  tissue,  caused  by  infection  with  Strepto- 
coccus erysipelatis,  and  accompanied  by  high  fever,  rapid  pulse,  and 
other  evidences  of  septic  intoxication.  The  local  appearances  are 
diffuse  redness  and  edema  of  the  skin,  with  sharply  defined  and  slightly 
raised  borders.  Infection  always  takes  place  through  some  wound 
or  break  in  the  skin,  although  the  point  of  infection  may  be  so  minute 
as  to  escape  detection.  From  this  point  it  spreads  rapidly,  and  may 
eventually  cover  the  entire  body.  When  the  disease  involves  the 
subcutaneous  cellular  tissue  the  symptoms  are  more  severe,  a  boggy 
induration  occurs,  followed  by  extensive  suppuration  and  often  by 
fatal  sepsis. 


INFLAMMATORY  DISEASES  OF  THE  FACE  AND  NECK     389 

Erysipelas  of  the  face  generally  begins  on  the  bridge  of  the  nose 
and  extends  on  cither  side  to  the  cheeks.  When  limited  to  these 
regions  it  may  present  only  a  butterfly-shaped  area  of  redness  without 
fever  or  general  symptoms  of  any  kind.  In  other  cases  more  or  less 
well-marked  constitutional  symptoms  may  be  present,  as  fever, 
chilly  sensations,  anorexia,  headache,  vomiting,  and  general  prostra- 
tion. If,  however,  the  disease  spreads  to  the  eyelids  and  scalp, 
edema  occurs,  closing  the  eyes  and  causing  considerable  disfigurement. 
In  erysipelas  of  the  scalp  the  redness  is  not  so  marked,  but  the  constitu- 
tional symptoms  are  more  severe.  Occasionally  the  infection  is 
carried  by  the  emissary  veins  to  the  intracranial  structures,  producing 
a  rapidly  fatal  meningitis. 

Erysipelas  of  the  ncch\  if  confined  to  the  skin,  presents  no  special 
features  worthy  of  mention. 

Treatment. — The  treatment  of  the  superficial  forms  of  erysipelas 
is  rather  unsatisfactory,  as  no  method  can  be  relied  upon  to  stop  the 
spread  of  the  disease  or  diminish  the  toxemia.  Small  patches  occurring 
on  the  face  may  sometimes  be  aborted  by  painting  with  contractile 
collodion,  or  the  application  of  lead-and-opium  wash.  In  other 
locations  the  use  of  a  wet  dressing  of  carbolic  acid  ( 1  to  200),  aluminium 
acetate,  lead-and-opium  wash,  or  an  ointment  of  ichthyol  (10  to  50 
per  cent.),  will  be  found  serviceable. 

Cellulitis. — In  the  neck  the  superficial  variety  differs  in  no  respect 
from  cellulitis  elsewhere,  the  diagnosis  and  treatment  of  which  have 
been  considered  in  Chapter  IX. 

Deep  Cellulitis  of  the  Neck  (Holzphlegmon.) — When  the  cellular  tissue 
beneath  the  deep  cervical  fascia  is  invaded,  which  usually  results  from 
a  suppurating  lymph  node,  the  disease  is  more  serious.  There  will 
be  at  first  pain  and  stiffness  of  the  neck,  with  edema  and  a  feeling  of 
deep-seated  induration  and  bogginess.  The  entire  lateral  region  of 
the  neck  will  appear  swollen,  but  redness  of  the  skin  is  rare.  Chills, 
fever,  sweats,  and  prostration  occur  early.  The  pus  may  burrow 
along  the  cellular  planes  and  eventually  reach  the  mediastinum. 
Septic  thrombosis  of  the  veins  may  occur  and  eventually  lead  to 
pyemia  and  death  from  exhaustion. 

Treatment. — The  treatment  of  cellulitis  should  consist  in  early 
incision  and  drainage.  The  incisions  should  be  free  and  sufficiently 
numerous  to  insure  adequate  drainage  for  every  pocket  of  pus. 

In  deep  cervical  cellulitis  the  incisions  should  be  made  over  or  just 
behind  the  sternomastoid  muscle  down  to  the  deep  fascia.  A  grooved 
director  should  then  be  thrust  through  the  muscle  or  fascia.  When 
pus  is  reached,  the  opening  should  be  enlarged  by  a  sinus-dilator  or 
pair  of  dressing-forceps  introduced  closed  and  withdrawn  open. 
The  cavity  should  then  be  explored  by  the  finger  or  some  blunt  instru- 
ment, and  another  incision  made  over  the  most  dependent  portion 
of  the  abscess.  Rubber  drainage-tubes  should  be  introduced  and 
a  wet  dressing  applied.     If  the  pus  has  burrowed  into  the  mediastinum, 


390  INJURIES  AND  DISEASES  OF  FACE  AND  NECK 

drainage  should  be  favored  by  raising  the  foot  of  the  bed  and  lowering 
the  head,  or  it  may  be  necessary  to  trephine  the  sternum. 

Angina  Ludovici. — Angina  Ludovici  is  a  violent  cellulitis  marked 
by  an  intense  hard,  brawny  swelling  with  widespread  edema,  showing 
little  or  only  a  late  tendency  to  break  down  and  form  pus,  situated 
in  the  submaxillary  triangle  extending  backward  behind  the  posterior 
border  of  the  mylohyoid  muscle  to  the  aryteno-epiglottidean  folds  and 
larynx  and  forward  along  the  upper  surface  of  mylohyoid  muscle,  beneath 
the  mucous  membrane  on  the  side  of  the  tongue  and  the  floor  of  the 
mouth.  This  cellular  tissue  surrounds  the  submaxillary  gland  and  is 
inclosed  within  a  fascial  and  muscular  recess  which  occupies  the  greater 
part  of  the  digastric  triangle.  In  this  areolar  tissue  there  are  imbedded 
a  number  of  lymph  nodes,  some  of  which  lie  in  contact  with  the  capsule 
of  the  gland.  The  disease  generally  arises  by  a  lymphatic  infection 
from  a  carious  tooth  or  some  other  septic  focus  in  the  mouth,  or  rarely 
from  a  septic  inflammation  of  the  submaxillary  gland.  The  disease  is 
always  serious.  In  virulent  cases  the  inflammation  develops  with 
great  rapidity,  causing  gangrene  of  the  areolar  tissue  and  neighboring 
structures,  with  a  rapidly  developing  sepsis  which  may  cause  death 
in  from  five  to  ten  days. 

Symptoms. — The  symptoms  are,  at  first,  often  those  of  an  acute 
infectious  disease:  chills,  fever,  thirst,  anorexia,  and  a  rapid,  full  pulse. 
Pain  is  not  always  an  early  symptom,  but  occurs  later,  and  is  often 
severe  and  throbbing  in  character.  A  painful  swelling  appears  under 
the  jaw,  sharply  limited  by  the  attachments  of  the  fascia.  The 
tongue  is  raised  and  the  floor  of  the  mouth  is  pushed  upward.  There 
often  result  edema  and  swelling  of  the  aryteno-epiglottidean  folds 
and  a  resulting  inspiratory  dyspnea.  The  temperature  is  usually 
not  greatly  elevated  but  the  pulse  is  apt  to  be  rapid.  There  is  generally 
a  high  leukocytosis.  Sudden  death  from  suffocation  is  frequently 
caused  by  edema  of  the  glottis. 

Treatment. — Treatment  should  be  undertaken  at  the  earliest  possible 
moment,  and  should  consist  in  free  incisions,  so  placed  as  to  relieve 
tension  on  the  structures  involved;  complete  removal  of  the  sub- 
maxillary gland  and  gangrenous  debris  will  be  indicated  in  all  but  the 
earliest  cases.  The  mylohyoid  muscle  should  be  divided  and  the 
space  beneath  the  floor  of  mouth  drained.  The  tissue  extending 
backward  toward  the  larynx  should  be  freely  exposed  with  thorough 
disinfection  of  the  cavity,  and  packing  with  sterile  gauze. 

Inflammation  and  Abscess  of  the  Parotid  Gland. — Inflammation  and 
abscess  of  the  parotid  gland  may  occur  from  pressure  in  drawing 
the  jaw  forward  during  anesthesia,  from  wounds,  from  an  ascending 
inflammation  of  the  duct,  or  from  infection  of  one  of  the  lymph  nodes 
imbedded  in  its  substance.  It  is  more  frequently,  however,  the  result 
of  some  general  septic  disease,  as  typhoid  fever,  scarlet  fever,  or  pyemia. 
The  disease  generally  begins  as  a  circumscribed  or  diffuse  indurated 
swelling  of  the  gland,  with  pain,  fever,  and  general  malaise.     The 


INFLAMMATORY  DISEASES  OF  THE  FACE  AND  NECK     391 

pain  is  increased  by  taking  food,  and  stiffness  of  the  temporomaxillary 
articulation  may  be  present.  After  several  days  the  mass  softens 
and  fluctuation  appears. 

Treatment. — The  treatment  is  by  incision  and  drainage.  Care 
should  be  taken  in  making  the  incision  to  avoid  wounding  the  external 
carotid  artery  or  the  branches  of  the  facial  nerve. 

Carbuncle. — This  disease,  the  nature  of  which  has  been  described 
on  page  19<S,  may  occur  on  any  portion  of  the  skin  of  the  face  and  neck. 
The  most  common  situation  is  on  the  back  of  the  neck,  near  the 
margin  of  the  hair.  It  begins  as  an  indolent  induration,  spreading 
generally  from  a  small  superficial  lesion,  as  an  infected  hair-follicle 
or  pimple.  The  swelling  is  at  first  painless  but  tender  to  the  touch; 
later  it  may  be  the  seat  of  throbbing  pain,  heat,  and  redness.  There 
are  stiffness  of  the 'neighboring  muscles  and  general  malaise.  The 
temperature  is  but  slightly  elevated,  and  the  patient  often  keeps  about, 
using  domestic  remedies  and  regarding  the  condition  as  simply  a 
"blind  boil,"  until  a  large  area  of  tissue  is  invoked.  .Superficial 
suppuration  occurs  at  a  number  of  points  which  slough  and  gradually 
coalesce,  forming  eventually  a  gangrenous  ulcer.  Symptoms  of  grave 
sepsis  appear  and  the  patient  rapidly  loses  flesh  and  strength,  and  if 
unrelieved  may  die  of  exhaustion. 

Treatment. — The  best  treatment  when  the  lesion  is  small  is  by  total 
excision  of  the  gangrenous  area  with  subsequent  wet  dressings  and,  if 
necessary,  skin-grafting.  When  this  is  impracticable,  crucial  incisions 
should  be  made  through  the  indurated  mass,  down  to  the  deep  fascia, 
the  flaps  should  then  be  raised  up  from  the  deep  fascia  and  the 
cavity  thus  formed  packed  with  sterile  gauze  soaked  in  liquid  alboline, 
and  later  separation  of  the  sloughs  favored  by  wet  dressings  or  poultices. 

The  condition  is  a  serious  one,  especially  in  the  aged  and  in  those 
debilitated  from  diabetes  and  other  exhausting  diseases.  A  rare 
but  particularly  fatal  form  of  carbuncle  occasionally  is  encountered 
on  the  upper  lip  or  cheek  which  in  malignancy  is  second  only  to  anthrax. 
The  reason  for  this  is  due  to  the  fact  that  in  these  cases  the  infection 
is  frequently  carried  upward  along  the  angular  vein  to  the  cerebral 
sinuses. 

Anthrax  or  Malignant  Pustule. — Anthrax  is  an  extremely  rare 
disease  in  this  country.  When  it  occurs  on  the  face  it  begins  by  a  small 
elevated  papule  surrounded  by  numerous  vesicles,  which  in  turn  are 
soon  surrounded  by  a  hard,  brawny  induration  involving  all  the  tissues 
of  the  lip  or  cheek.  The  vesicle  soon  ruptures  and  is  covered  by  a 
dark-brown  or  black  scab.  Later  the  entire  area  becomes  discolored, 
edema  of  the  surrounding  tissues  develops,  and  symptoms  of  grave 
sepsis  appear.  In  doubtful  cases  the  diagnosis  is  established  by 
finding  Bacillus  anthracis  in  the  fluid  of  the  vesicles.  Unless  a  mixed 
infection  occurs,  there  is  an  absence  of  pus  and  pain. 

Treatment. — The  treatment  should  consist  in  early  and  complete 
excision  of  the  diseased  area  and  the  neighboring  lymphatics,  followed 
by  wet  formalin  or  bichloride  dressings. 


392 


INJURIES  AND  DISEASES  OF  FACE  AND  NECK 


TUMORS  OF  THE  FACE  AND  NECK. 

A  large  variety  of  tumors  occur  in  the  tissues  of  the  face  and  neck, 
many  of  which  present  special  features. 

Dermoids. — These  occur  over  the  situation  of  any  of  the  embryonic 
fissures;  hence  they  are  apt  to  be  found  over  the  bridge  of  the 
nose,  about  the  orbit,  in  the  nasofacial  groove,  in  the  median  line  of 
the  lip  or  chin,  to  the  outer  side  of  the  angle  of  the  mouth,  about 
the  ear,  in  the  median  line  of  the  neck,  or  along  the  anterior 
margin  of  the  sternomastoid  muscle  at  points  corresponding  with 
the  branchial  clefts.  These  tumors  may  appear  as  small,  rounded, 
soft,  semifluctuating  masses  resembling  sebaceous  cysts.  They 
differ  from  the  latter,  however,  by  having,  as  a  rule,  deep  con- 
nections. Those  occurring  in  the  remnants  of  the  brachial  clefts 
are  often  intimately  connected  with  the  sheaths  of  the  great 
vessels  of  the  neck.     These  cvsts  generallv  contain  sebaceous  matter 


Dermoid  cyst  of  the  outer  canthus  of  the  eye. 


and  hairs;  rarely,  teeth  and  other  cutaneous  appendages  are  present. 
Occasionally  cysts  at  the  root  of  the  nose  and  about  the  orbit  are 
translucent  and  contain  a  substance  resembling  clear  olive  oil,  while 
the  deep-seated  branchial  cysts  may  contain  a  mucoid  material.  The 
growth  of  these  tumors  is  painless;  the}'  produce  symptoms  only  when 
they  press  upon  other  structures.  Epitheliomatous  changes  sometimes 
occur  in  dermoids,  especially  the  branchial  variety. 

Dermoids  are,  as  a  rule,  easily  enucleated,  and  early  removal  is 
to  be  advised  to  avoid  large  and  disfiguring  scars. 

Mandibular  tubercles  or  recesses,  small  auricular  sinuses  or  pedun- 
culated tumors  in  front  of  the  tragus,  branchial  fistulse,  colobomata,  are 
all  due  to  imperfect  closure  or  other  abnormalities  in  the  union  of  the 
various  embryonic  fissures.  Of  these  conditions,  only  the  branchial 
fistula?  and  the  various  forms  of  hare-lip  are  of  surgical  importance. 

Branchial  Fistulae. — Branchial  fistula?  may  occur  at  any  point  along 
the  anterior  border  of  the  sternomastoid  muscle,  or  even  in  the  median 
line  (Fig.  193).    They  are  all  due,  according  to  Jordan,  to  a  failure 


TUMORS  OF  THE  FACE  AND  NECK 


393 


of  complete  closure  of  the  second  branchial  cleft.  The  internal 
opening  is  always  in  the  neighborhood  of  the  tonsil.  In  the  lower 
portion  of  the  neck  the  fistulous  tract  lies  in  front  of  the  sternohyoid 
and  sternothyroid  muscles.  At  a  higher  point  it  is  deeply  seated, 
lying  behind  the  digastric  muscle,  between  the  external  and  internal 
carotid  arteries.  The  only  satisfactory  treatment  is  by  complete 
removal — an  extremely  difficult  and  often  dangerous  dissection. 


Fig.  193. — Branchial  fistula. 

Branchial  Cysts. — Branchial  cysts  are  comparatively  rare.  They 
may  occur  high  up  beneath  the  angle  of  the  jaw  or  at  any  point  along 
the  anterior  border  of  the  sternomastoid  muscle  (Fig.  194).  Occasion- 
ally they  reach  an  enormous  size  and  produce  great  disfigurement. 
Epitheliomatous  degeneration  of  a  branchial  cyst  may  occur,  and, 
as  a  rule,  these  cases  are  exceedingly  malignant  (Fig.  195).  Up  to 
1904  no  cure  by  operation  had  been  reported. 

Hare-lip  will  be  considered  on  page  414. 

Thyroglossal  Cysts  or  Fistulae. — The  thyroglossal  duct  is  an  embry- 
onic canal  leading  from  the  foramen  cecum  of  the  tongue  downward 
between  the  two  geniohyoglossus  muscles,  behind  or  through  the  body 
of  the  hyoid  bone,  in  front  of  the  thyrohyoid  membrane  and  thyroid 
cartilage,  to  the  isthmus  of  the  thyroid  gland.  A  failure  of  this  canal 
to  become  obliterated  may  result  in  a  blind  lingual  or  cervical  fistula 
or  the  formation  of  a  cyst,  either  above  or  below  the  hyoid  bone 
(Fig.  196).  If  above  the  hyoid,  the  cyst  may  occupy  the  body  of  the 
tongue  or  the  floor  of  the  mouth  (lingual  dermoid).     Such  a  tumor 


394 


INJURIES  AND  DISEASES  OF  FACE  AND  NECK 


may  grow  to  an  enormous  size,  causing  the  tongue  to  protrude  and 
seriously  interfere  with  deglutition.  Cysts  occurring  below  the  hyoid 
are  more  superficial,  and  generally  rupture  at  an  early  period  or 
suppurate,  leaving  a  median  sinus  which  secretes  a  small  amount  of 
mucus.  Lingual  dermoids,  if  small,  may  be  removed  by  a  median 
external  incision  just  below  the  symphysis,  or  by  a  semilunar  incision 
across  the  floor  of  the  mouth.  If  too  large  to  be  removed  through  the 
mouth,  the  cyst  should  be  evacuated  or  the  lower  jaw  may  be  divided 
in  the  median  line.  Median  cervical  fistulse  should  be  dissected  out 
up  to  the  body  of  the  hyoid. 


!_. 


Fig.  194. — Branchial  cyst.     (Warren  and  Gould.) 


Hygromata  of  the  Neck. — Hygromata  of  the  neck  are  large  cystic 
tumors  occupying  the  lateral  regions  of  the  neck,  often  growing  to  an 
enormous  size  and  giving  rise  to  great  deformity.  These  tumors  are 
thin-walled,  single  or  multiple  cysts,  and  represent  enormously  dilated 
spaces  resulting  from  embryonic  vascular  rests.  They  are  congenital, 
and  are  rarely  seen  in  adults  for  the  reason  that  they  are  frequently 
ruptured  in  childhood  and  as  a  result  undergo  spontaneous  cure  (Fig. 
197).     They  are  frequently  spoken  of  as  "hydroceles  of  the  neck,"  a 


TUMORS  OF  THE  FACE  AND  NECK 


395 


name  which  is  also  applied  to  the  mucous  or  deep  variety  of  branchial 
cysts.     Complete   removal  of  these  cysts  is  difficult  and   often   im- 


Fig.  195. — Carcinoma  of  branchial  cleft. 


Fig.  196. — Thyroglossal  cyst. 


possible,  owing  to  their  delicate  walls,  which  easily  rupture.  Incision 
and  drainage,  injections  of  iodine  and  other  irritating  fluids,  and 
partial  removal  frequently  result  in  a  cure. 


396 


INJURIES  AND  DISEASES  OF  FACE  AND  NECK 


Lipomata. — Lipomata  are  rare  on  the  face,  are  occasionally  found 
in  the  temporal  region,  and  are  comparatively  common  in  the  sub- 
cutaneous and  deeper  tissues  of  the  neck.  They  appear  as  soft, 
semifluctuating  bodies  which  grow  slowly  and  give  rise  to  no  dis- 
comfort. They  are  usually  tabulated  and  rarely  form  adhesions  to 
surrounding  structures.  Small  lipomata  require  no  treatment;  larger 
ones  should  be  removed.  A  grossly  deforming  type,  the  diffuse  lipoma 
of  the  neck,  differs  from  the  above,  in  that  it  is  not  definitely  circum- 
scribed, is  multiple,  and  often  grows  to  an  enormous  size.  It  is  most 
common  in  beer  drinkers  (Fig.  198).  The  removal  of  these  tumors  is 
often  difficult  and  requires  a  laborious  and  tedious  dissection. 


Fig.  197. — Cystic  hygroma  of  the  neck. 


Fig.  198. — Diffuse  lipoma  of  the  neck. 


Fibromata,  fibroneuromata,  angiomata,  hemorrhagic  and  bursal 
cysts,  aneurisms  of  the  various  arteries,  and  other  innocent  tumors 
present  no  special  features  when  they  occur  in  these  regions;  their 
diagnosis  and  treatment  have  already  been  considered. 

Epitheliomata. — Squamous  epitheliomata  and  the  small  basal  cell 
variety  occur  on  the  face,  the  former  generally  at  the  mucocutaneous 
junction,  the  latter  on  the  skin  of  the  cheek,  generally  in  the  neighbor- 
hood of  the  orbit.  Excluding  the  lower  lip,  squamous  epithelioma 
occurs  most  frequently  on  the  nose,  cheeks,  and  eyelids;  very  rarely 
on  the  upper  lip  or  chin.  The  disease  grows  slowly  at  first,  but  at  a 
later  period  advances  more  rapidly  and  involves  the  submaxillary 
and  cervical  lymphatics. 

In  the  small  basal  cell  growths  there  is  rarely  involvement  of  the 
lymphatics,  and  visceral  metastasis  never  occurs. 


TUMORS  OF  THE  FACE  AND  NECK 


397 


Treatment. — The  treatment  of  the  squamous  variety  should  be  by 
wide  excision,  often  necessitating  plastic  repair  and  extirpation  of  the 
anatomically  related  lymph  nodes.  In  the  small  cell  variety  only  local 
removal  is  necessary,  or  the  employment  of  radium  or  the  x-rays. 

Epithelioma  of  the  Lip. — This  is  the  most  important  and  most 
frequently  observed  type  of  malignant  growth  of  the  face.  In  the 
great  majority  of  cases  it  occurs  on  the  lower  lip  in  men  past  middle 
life.  It  may  begin  as  a  small  wart-like  nodule,  as  a  superficial  erosion, 
or  as  a  fissure.  At  first  the  growth  may  be  exceedingly  slow,  but  at  a 
later  period  it  extends  more  rapidly,  infiltrates  the  deeper  structures 
and    involves   the    neighboring   lymphatics.     (See   frontispiece.)     In 


Fig.  199. — Sarcoma  of  neck. 


neglected  cases  the  disease  invades  the  jaw  bone,  and  the  lymphatic 
extension  gives  rise  to  large  infiltrating  tumors  of  the  neck,  which 
finally  ulcerate  and  cause  great  disfigurement. 

Treatment. — The  treatment  of  cancer  of  the  lip,  to  be  successful, 
must  be  undertaken  in  the  early  stage  of  the  disease,  as  late  operations 
favor  rapid  extension  and  visceral  metastasis. 

When  the  growth  is  small  and  superficial,  it  may  be  removed  by 
a  V-shaped  incision  and  removal  of  the  contents  of  the  submaxillary 
triangle  on  the  side  of  the  lesion.  If  located  in  the  median  line  both 
submaxillary  regions  should  be  explored  and  all  diseased  lymphatics 
removed.     When  the  disease  is  more  advanced  the  entire  lower  lip 


398 


IX JURIES  AXD  DISEASES  OF  FACE  AXD  XECK 


should  be  excised,  and  the  lymphatic  dissection  should  include  also 
the  upper  jugular  nodes.  The  defect  left  after  removal  of  the  lip 
should  be  repaired  by  some  form  of  plastic  operation. 

Sarcomata. — As  in  other  portions  of  the  body,  sarcoma  here  may 
develop  in  any  tissue  of  mesoblastic  origin.  Sarcoma  of  the  eyeball 
occurs  in  two  forms,  the  retinal  sarcoma  or  glioma  of  children,  and 
the  malanotic  sarcoma  of  adults  which  arises  from  the  uveal  tract. 
Two  clinical  varieties  occur  in  the  tissues  of  the  neck,  those  arising 
from  the  facia?  and  those  arising  from  the  lymph  nodes.  The  latter 
may  be  primary  or  secondary  to  sarcomata  of  the  salivary  glands  or 
tissues  of  the  nasal  or  oral  cavities  (Fig.  199). 

Treatment. — The  treatment  of  all  of  these  varieties  has  already 
been  considered. 

Tumors  of  the  Salivary  Glands. — Carcinoma  occurs  frequently  in 
the  parotid  in  individuals  past  middle  life,  causing  a  rapidly  growing 
tumor  which  infiltrates  the  surrounding  tissues  and  early  gives  rise  to 

lymphatic   metastases.     It   is   rarer   in    the 
submaxillary  and  sublingual  glands. 

Endothelioma  may  occur  in  any  one  of 
the  salivary  glands,  and  at  any  period  of 
life,  although  the  disease  is  rare  in  child- 
hood and  old  age.  In  the  parotid  the 
growth  may  be  rapid  or  slow.  The  slowly 
growing  endotheliomata  are  generally  com* 
posed  of  glandular  masses,  myxomatous 
cysts,  cartilage,  and  fibrous  tissue — the  so- 
called  mixed  tumors  of  the  parotid  (Fig. 
200).  They  are  innocent  or  feebly  malig- 
nant. In  the  submaxillary  and  sublingual 
glands  the  disease  resembles  carcinoma,  is 
inn     „  ,  x,  ,.  ,    more    rapid,     and     sometimes    exceedingly 

200. — Endothelioma   of  ■  .  xr-r-w 

parotid.  malignant  (Flate   XI \  ). 


Fig. 


SURGERY  OF  THE  THYROID  GLAND.1 

Anomalies. — The  isthmus  is  absent  in  about  10  per  cent,  of  cases.  A 
pyramidal  process,  occasionally  double,  is  present  in  about  50  per  cent. 
of  cases,  projecting  upward  from  the  isthmus  in  or  near  the  midline. 

Accessory  or  aberrant  thyroids  are  masses  of  thyroid  tissue  of 
variable  size  which  occasionally  occur  in  the  neck,  especially  in  the 
vicinity  of  the  thyroid.     They  may  give  rise  to  tumors  or  cysts. 

The  exact  function  of  the  thyroid  is  unknown;  however,  a  sufficiency 
of  thyroid  tissue  is  essential  for  normal  metabolism.  A  deficiency  of 
thyroid  results  in  the  well-known  disturbances  of  metabolism  evidenced 
in  myxedema.     Colloid  is  the  normal  secretion  of  the  gland;  presum- 

1  A  large  part  of  this  section  is  an  abstract  of  an  article  by  Dr.  Pool  in  Johnson's 
Surgical  Therapeusis. 


PLATE  XIV 


Endothelioma  of  Submaxillary  Gland. 


SURGERY  OF   THE  THYROID  GLAND 


399 


ably  the  function  of  the  gland  is  carried  on  by  the  passage  of  the 
secretion  into  the  circulation.  Iodine  is  present  in  relatively  large 
amount  combined  with  protein,  the  product  being  known  as  iodothyrin 
or  iodothyroglobulin.  Efforts  have  been  made  to  define  the  physio- 
logical importance  of  the  iodine;  the  main  result  has  been  to  establish 
the  fact  that  iodine  will  lessen  the  anatomical  manifestations  of  the 
activity  of  the  thyroid  (Marine).  Some  writers  in  the  study  of  the 
thyroid  have  taken  the  iodine  content  as  a  true  index  of  the  functional 
activity  of  the  gland,  but  deductions  based  upon  this  unproved  assump- 
tion cannot  be  accepted. 

That  there  is  a  correlation  between  the  functions  of  the  various 
glands  of  internal  secpetion  is  now  generally  believed.     But  in  what 


Fig.  201.— Goitre. 


manner  and  to  what  extent  the  thyroid  affects  and  is  affected  by  the 
parathyroids,  thymus,  pituitary,  adrenals,  pancreas,  spleen  and 
generative  organs  is  hypothetical. 

Goitre. — The  term  goitre  includes  simple  goitre,  exophthalmic 
goitre  and  malignant  goitre. 

Simple  Goitre. — Simple  goitre  (struma,  bronchocele)  is  a  chronic 
recognizable  enlargement  of  the  thyroid  which  is  not  definitely  an 
incident  of  inflammation,  is  not  malignant  and  with  which  the  toxic 
symptoms  which  constitute  exopthalmic  goitre  are  not  associated. 
As  we  will  show  later,  there  is  a  small  group  of  cases  which  must  be 
designated  "complicated  simple  goitre"  which  present  toxic  symptoms 
akin  to  those  of  exophthalmic  goitre.  Between  these  and  exophthalmic 
goitre  differentiation  is  often  difficult. 


400  INJURIES  AND  DISEASES  OF  FACE  AND  NECK 

Etiology. — Goitre  occurs  endemically  in  places,  especially  certain 
mountainous  districts;  it  occurs  sporadically  elsewhere.  It  is  more 
frequent  in  women  than  in  men.  The  enlargement  of  the  thyroid 
usually  begins  during  adolescence,  less  often  in  childhood  or  in  later 
life.  Circulatory  disturbances  in  the  gland,  as  the  result  of  puberty, 
pregnancy,  occupations  or  habits  which  produce  congestion  of  the 
vessels  of  the  neck,  appear  to  favor  the  development  of  goitre. 

The  underlying  cause  of  goitre  is  unknown,  but  the  general  belief  has 
long  prevailed  that  goitre  is  due  to  some  peculiarity  of  the  drinking- 
water,  especially  of  glacial  waters.  Certain  experimental  and  clinical 
observations  suggest  that  this  peculiarity  of  the  drinking-water  is  due 
to  some  substance  which  is  derived  from  the  soil,  and  that  this 
substance  is  probably  organic  and  possibly  bacterial. 

Recent  writers  classify  goitre  as  follows: 

Diffuse  goitre,  in  which  the  whole  gland  is  affected:  (1)  Diffuse 
parenchymatous  or  follicular  goitre,  (2)  colloid  goitre. 

Nodular  goitre,  in  which  only  a  part  of  the  gland  is  affected:  (1) 
Adenomata:  (a)  fetal,  (b)  adult;  (2)  cysts:  (a)  from  hemorrhage, 
(b)  in  adenomata,  (c)  colloid.  It  must  be  emphasized  that  several 
lesions  are  frequently  found  in  a  single  gland. 

Pathological  changes:  Diffuse  parenchymatous  (follicular)  goitre. 
The  whole  thyroid  is  moderately  enlarged  and  soft.  There  is  an 
increase  in  the  number  of  acini.  The  acini  are  normal  or  only  slightly 
changed. 

Colloid  goitre  is  a  generalized  enlargement  of  the  thyroid  gland 
due  chiefly  to  an  increase  in  the  colloid.  The  gland  may  reach  a  large 
size.  The  surface  is  lobulated;  the  consistency  firmer  than  normal; 
the  cut  section  exudes  colloid.  The  acini  are  larger  than  normal, 
the  cells  may  be  normal  or  somewhat  flattened,  the  colloid  stains 
more  deeply  and  completely  fills  the  follicles;  if  adjacent  follicles 
coalesce  and  excessive  colloid  accumulates,  a  colloid  cyst  may 
result. 

Nodular  (Asymmetrical)  Goitres. — Adenomata. — Adenomata  are  of 
frequent  occurrence.  They  are  often  first  noticed  during  adolescence. 
They  may  occur  as  independent  lesions  or  in  association  with  diffuse 
goitre.  They  are  oval  or  round,  completely  encapsulated  tumors  which 
vary  greatly  in  size  and  number.  They  may  be  single,  or  there  may  be 
so  many  that  the  gland  becomes  a  nodular  mass  (McCarty).  The 
capsule  of  adenomata  is  fibrous  connective  tissue,  which  varies  greatly 
in  thickness  and  density.  It  is  often  calcareous.  The  cut  surface  of 
the  undegenerated  tumor  is  firm  and  uniform. 

Two  groups  of  adenomata  may  be  differentiated,  namely,  fetal 
adenomata,  so  named  from  the  histological  resemblance  to  the  fetal 
thyroid  tissue;  and  adult  adenomata,  which  conform  to  the  type  of 
normal  thyroid  tissue.  Secondary  changes,  such  as  calcification, 
hemorrhage  and  cyst  formation  are  frequent. 

Cysts  are  frequent  lesions.     They  are  described  by  Marine  as  follows : 


SURGE h'Y  OF  THE  THYROID  GLAND  401 

A.  Cysts  Dependent  on  Hemorrhage  into  Follicles. — -These  are  the 
usual  thyroid  cysts.  They  vary  in  size  from  a  few  millimeters  to 
6  or  8  cm.  in  diameter.  The  smaller  ones  have  the  slightly  thickened 
follicular  walls  as  their  cyst  walls,  while  the  larger  cysts  include  in 
addition  to  the  follicular  walls,  portions  of  the  gland  capsule  or  tra- 
becular, together  with  a  new  formation  of  connective  tissue.  In  such 
cyst  walls  calcification  is  occasionally  seen.  The  cyst  contents  consist 
of  blood  in  various  stages  of  decomposition,  mixed  with  more  or  less 
colloid. 

B.  Cysts  Originating  from  Adenomata. — Cyst  formation  in  adeno- 
mata is  common.  The  primary  change  probably  is  an  interference 
with  the  nutrition  of  the  interior  of  the  tumor  resulting  in  central 
necrosis.  Hemorrhage  then  takes  place.  Usually  there  may  be  seen 
in  these  cystic  adenomata  a  zone  of  living  tissue  beneath  the  capsule. 
The  original  capsule  of  the  adenoma  makes  the  cyst  wall.  Calcification 
of  the  fibrous  capsule  is  sometimes  present.  Cysts  of  this  origin 
make  up  the  largest  cysts  of  the  thyroid  and  are  those  usually  treated 
surgically. 

C.  Colloid  cysts  (as  described  above). 

In  its  growth  a  simple  goitre  may  produce  marked  changes  as  a 
reeult  of  pressure  on  adjacent  structures,  especially  upon  the  trachea. 
A  goitre  developing  from  an  accessory  thyroid  within  the  mediastinum 
(retrosternal)  is  especially  prone  to  produce  pressure  symptoms  by 
reason  of  its  confined  position. 

Symptoms. — On  inspection  there  is  noted  in  the  lower  and  anterior 
part  of  the  neck  a  swelling  corresponding  to  the  position  of  the  thyroid. 
It  may  be  diffuse  and  symmetrical  and  correspond  to  the  whole  thyroid, 
or  nodular  and  asymmetrical,  corresponding  to  a  part  of  the  thyroid. 
The  distribution  and  the  size  of  the  swelling  depend  upon  the  character 
of  the  lesion.  Thus,  in  diffuse  parenchymatous  goitre  the  lower  part 
of  the  neck  is  diffusely  and  moderately  enlarged;  the  condition  is 
termed  "thick  neck"  in  certain  districts.  In  diffuse  colloid  goitre 
the  enlargement  may  be  extreme.  Adenomata  and  cysts  produce 
asymmetrical  enlargement  of  variable  size;  such  goitres  are  frequently 
very  large. 

The  parenchymatous  goitre  feels  smooth,  soft  and  elastic;  the 
colloid,  firm  or  hard,  lobulated  and  at  times  nodular.  Asymmetrical 
or  nodular  goitres  vary  from  hard  in  calcareous  adenomata  to  elastic 
in  superficial  cysts  with  thin  walls. 

On  swallowing  the  goitre  is  seen  and  felt  to  move  upward,  by  reason 
of  the  attachment  of  the  thyroid  to  the  trachea,  a  feature  which  is  of 
importance  in  diagnosis. 

Pain  is  not  usual  in  simple  goitre.  Tenderness  indicates  an  inflam- 
matory process. 

Symptoms  due  to  pressure  upon  the  trachea  are  dyspnea  and 
stridor.  Dyspnea,  produced  by  pressure  upon  the  trachea,  is  by  far 
the  most  frequent  and  important  of  the  pressure  symptoms.  It  may 
26 


402  INJURIES  A.XD  DISEASES  OF  FACE   AND   NECK 

be  of  gradual  development  from  the  growth  of  a  readily  recognizable 
goitre  or  of  a  concealed  goitre  developing  within  the  thorax;  or  it  may 
develop  suddenly  as  the  result  of  hemorrhage.  A  number  of  cases 
have  been  reported  of  hemorrhages  into  cysts  which  demanded  im- 
mediate surgical  intervention.  The  dyspnea  may  be  constant  or 
paroxysmal;  it  may  become  so  severe  as  to  cause  death. 

Stridor. — When  the  lumen  of  the  trachea  is  considerably  narrowed, 
loud  whistling  inspiration  and  expiration  result,  the  characteristic 
tracheal  stridor. 

Pressure  on  a  recurrent  nerve  with  unilateral  paralysis  of  the  laryn- 
geal muscles  is  not  unusual.  It  frequently  causes  irritating  cough 
or  hoarseness,  though  at  times  unilateral  paralysis  gives  no  symptoms. 
The  condition  is  usually  one  of  adductor  paralysis,  that  is,  the  cord  lies 
in  a  partially  abducted  position,  toward  the  side  of  the  larynx,  and  does 
not  draw  nearer  the  midline  in  phonation.  Symptoms  due  to  paralysis 
of  one  recurrent  may  be  absent  by  reason  of  compensatory  hyper- 
activity of  the  healthy  cord.  Laryngeal  examination  is  always  indi- 
cated before  operation. 

Pressure  on  the  sympathetic  rarely  occurs.  It  may  cause  irregularity 
of  the  pupils,  increased  sweating  of  the  face,  increase  in  color  and 
temperature  of  the  affected  side  of  the  face.  The  bracheal  plexus  and 
even  the  spinal  accessory  may  be  affected  in  large  goitres. 

Rarely  dysphagia  results  from  pressure  on  the  esophagus. 

Venous  stasis,  causing  edema  and  cyanosis,  may  result  from  pressure 
on  the  veins  that  drain  the  head,  neck  and  arms;  cyanosis  is  particu- 
larly marked  during  exertion. 

The  heart  may  be  affected  in  cases  of  simple  goitre  as  a  result  of 
mechanical  obstruction  to  the  blood  flow  to  or  from  the  heart,  or  inter- 
ference with  respiration  by  the  tumor.  Mechanical  obstruction 
may  give  rise  to  hypertrophy  and  dilatation. 

"There  may  occur  with  any  simple  goitre,  but  especially  with  single 
or  multiple  adenomata,  a  slow  chronic  toxic  condition  somewhat  like 
the  acute  toxemia  of  exophthalmic  goitre.  In  most  cases  a  long  period 
elapses  between  the  appearance  of  the  goitre  and  the  thyrotoxic 
symptoms;  the  average  time  is  about  fourteen  and  a  half  years" 
(  Mayo  and  Plummer) .  Kocher  attributes  some  of  these  cases  to  the  long 
use  of  iodine.  The  main  symptoms  are  dependent  upon  dilatation  of 
the  heart,  nephritis  and  myocardial  insufficiency.  The  last  may  cause 
signs  of  profound  stasis  including  general  anasarca.  Other  symptoms, 
including  tremor,  tachycardia,  nervousness,  loss  of  weight  and  strength 
may  be  present.  "True  exophthalmus  does  not  occur  in  these  cases, 
but  the  myocardial  change  may  cause  a  widening  of  the  palpebral 
fissure.  These  cases,  often  called  Graves'  disease,  should  be  classed 
as  complicated  simple  goitre." 

Course  and  Prognosis  of  Simple  Goitre. — A  simple  goitre,  as  a  rule, 
increases  progressively  in  size  until  about  middle  life.  It  occasionally 
is  the  cause  of  death  through  stenosis  of  the  trachea,  which  may  be 


SURGERY  OF  THE  THYROID  GLAND  403 

gradual,  from  the  growing  goitre,  or  sudden,  from  hemorrhage.  Impair- 
ment of  the  heart  may  affect  the  health  of  the  patient.  In  rare  cases 
a  malignant  neoplasm  develops  in  the  goitrous  gland. 

Treatment.  -Medical. — Upon  most  simple  goitres  medical  treatment 
appears  to  have  little  effect;  however,  in  diffuse  parenchymatous 
and  colloid  goitres  of  adolescence  several  periods  of  iodine  medication 
should  be  enforced  before  operation  is  recommended  (Kocher). 

The  indications  for  operative  intervention  in  simple  goitre:  1 .  Pressure 
disturbances  upon  the  trachea  causing  dyspnea;  on  the  esophagus 
causing  dysphagia;  on  a  recurrent  laryngeal  neive,  causing  irritating 
cough  or  hoarseness;  on  the  nerves  of  the  brachial  plexus  or  the  great 
vessels. 

2.  Suspicion  of  malignancy.  This  is  suggested  by  sudden  develop- 
ment or  rapid  increase  in  the  size  of  a  goitre,  or  by  sensitiveness  or 
pain,  especially  in  advanced  life. 

3.  Deformity  or  discomfort. 

4.  Abnormally  situated  goitres.  Intrathoracic  goitres  should  be 
operated  upon  as  early  as  possible.  Lingual  goitres  call  for  interfer- 
ence only  if  they  cause  symptoms. 

5.  Symptoms  of  toxemia. 

Surgical  Procedures. — A  number  of  surgical  procedures  for  the 
treatment  of  simple  goitre  are  at  the  disposal  of  the  operator 
whose  choice  must  depend  upon  the  individual  indications  of  the, 
case. 

Excision  or  extirpation  of  one  lobe  is  the  safest  procedure  and  is 
thoroughly  satisfactory  in  appropriate  cases.  It  is  especially  indicated 
in  diffuse  goitre  with  or  without  resection  of  the  second  lobe;  but 
excision  may  be  employed  advantageously  in  nodular  goitres  which 
are  composed  of  multiple  adenomata  or  cysts  which  cannot  be  enu- 
cleated. When  the  isthmus  is  diseased  or  is  readily  removable  it  is 
excised  together  with  the  lateral  lobe.  A  pyramidal  lobe  is  also 
usually  removed.  Bilateral  excision,  that  is,  complete  removal  of 
both  lateral  lobes,  should  never  be  performed  in  simple  goitre. 

Resection  offers  the  advantage  of  safeguarding  the  parathyroids 
and  the  recurrent  nerve  and  may  be  employed  under  the  following 
conditions : 

1.  In  diffuse  goitre  when  unilateral  excision  has  already  been 
performed  at  the  same  or  at  a  previous  operation.  Under  such  con- 
ditions the  posterior  part  of  the  second  lobe  must  be  left  to  ensure  a 
sufficiency  of  parathyroids. 

2.  In  large  bilateral  diffuse  goitres  bilateral  resection  may  be 
employed  advantageously  to  produce  a  symmetrical  result. 

Enucleation  consists  in  the  separation  of  a  discreet  tumor  from 
the  thyroid  tissue.  It  is  employed  for  cysts  and  encapsulated  adeno- 
mata.    The  method  should  be  elected  when  feasible. 

Exenteration  and.  Incision  of  Cysts.- — These  are  effective  procedures 
for  the  relief  of  pressure. 


404  INJURIES  AND  DISEASES  OF  FACE  AND  NECK 

Isthmectomy  has  been  performed  occasionally  for  the  relief  of  pressure 
upon  the  trachea.  While  it  has  been  effective  in  some  cases  the  result 
is  usually  disappointing. 

Tracheotomy  is  rarely  indicated. 

Results. — The  mortality  rate  in  operations  for  simple  goitre  may  be 
estimated  conservatively  at  less  than  1  per  cent,  in  the  hands  of 
skilful  surgeons.  Pressure  disturbances  usually  subside  after  opera- 
tion. Occasionally  the  muecles  of  the  larynx  do  not  resume  their 
function  if  a  recurrent  laryngeal  nerve  has  been  involved  for  a 
considerable  time  or  has  been  injured  during  the  operation. 

Hyperthyroidism. — Hyperthyroidism  or  thyrotoxicosis  is  "the 
constitutional  state  associated  with  enlargement  of  the  thyroid  or 
goitre"  and  presumably  due,  in  part  at  least,  to  thyroid  intoxication. 
The  terms  include  the  toxemias  at  times  noted  in  the  course  of  simple 
goitre,  as  well  as  the  systemic  disturbances  occurring  in  exophthalmic 
goitre.  The  two  conditions  should  be  differentiated.  While  every 
case  of  exophthalmic  goitre  presents  hyperthyroidism,  not  every 
hyperthroidism  is  exophthalmic  goitre.  To  avoid  confusion  we  will 
use  the  term  "exophthalmic  goitre"  instead  of  "hyperthyroidism" 
in  discussing  the  condition  about  to  be  described. 

Exophthalmic  Goitre. — Exophthalmic  goitre  {Graves  disease,  Base- 
dow's disease)  consists  in  a  peculiarly  variable  group  of  symptoms  the 
chief  of  which  are  enlargement  of  the  thyroid,  exophthalmos,  tachy- 
cardia and  tremor,  with  which  are  associated  others  less  constant 
and  less  characteristic. 

Etiology. — Although  the  symptoms  of  the  disease  appear  to  be 
caused  primarily  by  increased  production  and  absorption  of  thyroid 
secretion,  recent  investigations  suggest  that  the  disease  is  in  reality 
due  to  a  polyglandular  lack  of  balance.  Persistence  of  the  thymus 
and  functional  derangements  of  other  ductless  glands  also  seem  to 
modify  the  symptom-complex.  The  whole  question,  however,  is 
hypothetical. 

Women  are  much  more  subject  to  exophthalmic  goitre  than  men. 
Most  cases  occur  between  adolescence  and  middle  life.  In  many  cases 
exhaustion  of  the  nervous  system  from  various  causes  precedes  the 
development  of  the  symptoms  and  appears  to  be  of  etiological 
importance. 

Pathology. — In  the  large  majority  of  cases  of  exophthalmic  goitre 
there  is  diffuse  hypertrophy  and  hyperplasia  of  the  thyroid  paren- 
chyma. The  changes  vary  from  a  slight  departure  from  normal 
(hypertrophy)  early  in  the  disease  and  in  mild  cases,  to  a  marked 
proliferation  (hyperplasia)  later  and  with  intense  signs. 

Hyperplasia  of  the  thymus  is  of  usual  occurrence,  enlargement  of 
the  spleen  and  increase  in  lymphoid  tissue  injgeneral  is  frequent. 
The  heart  often  shows  hypertrophy  and  later  dilatation.  Patty  liver 
and  chronic  nephritis  are  found  late  in  the  disease. 


SURGERY  OF   THE   THY  RON)  GLAND 


405 


Symptoms. — The  symptoms  and  objective  signs  of  exophthalmic 
goitre  will  be  enumerated  briefly;  an  elaborate  description  of  them  is 
unnecessary  since  they  are  fully  described  in  all  text-books  of  medicine. 

Thyroid  enlargement  can  usually  be  appreciated,  but  the  degree 
varies  from  very  slight  fulness  of  the  neck  tojarge'goitre;  the  swelling 
is  usually  soft,  elastic  and  uniform;  it  may  pulsate;  frequently  murmurs 
can  be  heard  and  a  thrill  felt  over  the  goitre.  Exophthalmos  from 
very  slight  to  marked  protrusion  is  present  in  50  per  cent,  of  cases. 
There  is  no  defect  of  vision.  Certain  peculiarities  in  the  movements 
of  the  eyes  have  been  described,  and  when  present  are  of  some  aid  in 


Fig.  202. — Exophthalmic  goitre. 


diagnosis.  Stellwag's  sign :  staring  with  diminished  frequency  of  wink- 
ing. Dalrymple's  sign:  widening  of  palpebral  fissure  showing  exces- 
sive surface  of  sclera  around  cornea.  Von  Graef's  sign:  lagging  of 
upper  lid  in  downward  movement  of  eyes.  Kocher's  sign:  lagging 
of  lower  lid  in  upward  movement  of  eyes.  Moebius'  sign:  loss  of 
power  of  convergence. 

Palpitation  and  tachycardia  are  among  the  most  frequent  symptoms. 
The  heart  is  often  hypertrophied  and  dilated;  there  are  often  accom- 
panying cardiac  murmurs.  Tremor  and  loss  of  muscular  power  are 
usually  present.     The  patient  usually  shows  irritability,  excitability, 


406  INJURIES  AND  DISEASES  OF  FACE  AND  NECK 

loss  of  mental  equilibrium  and  various  degrees  of  mental  disturbance, 
even  including  delirium  and  mania.  The  skin  is  warm  and  moist, 
there  is  often  sweating  of  the  palms  of  the  hands  and  feet,  and  occasional 
flushes.  Dyspnea  is  not  infrequent.  Thirst,  vomiting  and  diarrhea 
often  occur.  Peculiarities  in  the  pigmentation  of  the  skin  are  some- 
times noted.  Emaciation  is  usual  and  is  rapid  in  unfavorable  cases. 
Albuminuria,  polyuria  and  glycosuria  are  noted  in  some  cases.  There 
may  be  alimentary  or  adrenalin  glycosuria.  There  is  often  noted  a 
relative  and  absolute  diminution  of  the  polymorphonuclear  leukocytes; 
the  mononuclear,  especially  the  small  mononuclears,  being  above 
normal. 

Of  these  symptoms  those  which  are  the  most  significant  are  tachy- 
cardia, tremor,  exophthalmos,  goitre,  emaciation,  attacks  of  diarrhea 
and  disorders  of  the  brain  and  nervous  system. 

Treatment. — Medical  treatment  is  directed  toward  diminishing  the 
effects  of  the  acute  toxemia  and  avoiding,  limiting  or  delaying  the 
secondary  disturbances,  especially  the  circulatory.  Surf/teal  treat- 
ment is  directed  toward  reducing  the  thyroid  secretion.  Both  opera- 
tive and  non-operative  procedures  are  essential  in  the  treatment  of 
the  disease.  llest,  both  mental  and  physical,  stands  first  in  impor- 
tance. Next  to  rest  comes  food,  which  should  be  abundant  and 
simple.  Drugs  should  be  used  for  the  most  part  symptomatically. 
Although  no  drug  has  a  specific  action  in  the  disease,  quinine 
hydrobromate  (gr.  v,  three  times  a  day)  is  employed  extensively  and 
benefit  apparently  results  in  some  cases  from  its  use.  There  are  many 
therapeutic  agents  which  have  been  widely  employed,  for  the  most 
part  empirically,  with  varying  success.  These  include  animal  extracts, 
iodothyroglobulin  and  antithyroid  serum. 

Surgical  Treatment. — Operative  Indications. — It  must  be  emphasized 
that  these  cases  are  bad  operative  risks,  yet  it  is  the  consensus  of 
opinion  among  experienced  surgeons  that  curtailment  of  the  secretion 
of  the  thyroid  gland  through  limitation  of  its  blood  supply  or  diminu- 
tion of  its  secreting  tissue  is  the  ideal  therapeutic  procedure. 

When  cases  are  seen  in  an  early  stage,  a  trial  of  non-operative 
measures  is  advisable.  Occasionally  cures  result.  If  improvement  is 
not  strikingly  marked  within  three  or  certainly  six  months,  operation 
is  indicated,  unless  definite  contra-indications  are  present. 

In  a  late  stage  or  in  acutely  active  periods  of  the  disease  a  preparatory 
course  of  medical  treatment  is  imperative,  the  aim  being  to  improve 
the  condition  of  the  patient  so  that  operation  may  be  undertaken 
with  comparative  safety. 

The  principal  contra-indications  to  operation  are: 

1.  Evidence  of  myxedema, 

2.  Status  thymicolymphaticus. 

3.  Cases  which  present  degeneration  of  the  heart  muscle,  with  low 
blood-pressure,  irregular  pulse  and  periodic  attacks  of  delirium  cordis, 
that  is,  extreme  rapidity  of  the  heart  with  very  irregular  pulse  (Kocher). 


SURGERY  OF  THE   THYROID  GLAND  4<i, 

However,  unless  the  heart  is  seriously  affected,  judicious  preliminary 
treatment,  as  a  rule,  brings  about  sufficient  improvement  to  warrant 
operation. 

The  operative  procedures  which  have  been  adopted  and  are  now 
generally  used  for  the  control  of  the  thyroid  secretion  are  ligation  of 
vessels  and  partial  thyroidectomy. 

Vascular  ligature  for  exophthalmic  goitre  was  advocated  as  a  means 
of  diminishing  the  secretion  of  and  absorption  from  the  gland.  As 
the  result  of  ligation  alone  the  symptoms  are  often  very  favorably 
affected;  in  some  cases  complete  cure  results  (Mayo). 

Partial  thyroidectomy  is  undoubtedly  the  most  efficient  treatment, 
operative  or  otherwise.  The  amount  to  remove  is  the  important 
feature.  While  from -one-sixth  to  one-quarter  of  the  gland,  that  is, 
about  one-half  of  a  lobe,  is  said  to  be  sufficient  to  supply  the  necessities 
of  the  body,  provided  the  part  left  is  capable  of  functionating  in  a 
normal  manner,  it  is  the  limit  of  safety.  Whereas,  in  general  removal 
of  about  three-quarters  of  the  gland,  that  is,  one  lobe  and  one-half 
of  the  other  lobe  will  give  a  greater  guarantee  of  complete  and  rapid 
cure  of  the  hyperthyroidism  than  the  removal  of  smaller  portion;  in 
attempting  to  approach  the  limit  of  safety  too  closely  there  is  danger, 
although  slight,  of  overstepping  it  with  resulting  myxedema,  while 
dangers  of  hemorrhage  and,  most  important  of  all,  of  acute  toxemia 
are  increased  by  resection.  Therefore  the  disadvantages  of  removing 
too  much  and  the  possibility  of  resorting  to  subsequent  resections  if 
insufficient  tissue  has  been  removed  at  the  first  operation,  definitely 
indicate  a  conservative  policy. 

Thymectomy. — Extirpation  of  the  thymus  has  been  recommended 
and  performed  in  a  few  cases  for  the  treatment  of  the  disease;  it  must 
be  regarded,  however,  as  being  in  the  experimental  stage. 

Sympathectomy  was  formerly  practised,  but  has  been  generally 
abandoned.  The  results  have  been  extremely  variable  and  cures 
as  a  result  of  the  procedure  have  been  exceptional.  Mayo,  however, 
recommends  the  procedure  for  cases  with  small  goitre  and  extreme 
exophthalmos. 

Injection  into  the  substance  of  the  gland  was  formerly  practised, 
but  was  generally  discarded  as  a  blind  and  dangerous  procedure. 
Porter  has  recently  recommended  the  injection  of  hot  water. 

Summary  of  Choice  of  Operative  Procedures. — In  early  and  mild  cases 
the  superior  thyroid  vessels  of  both  sides  are  ligated  at  one  operation. 

In  severe  cases  the  superior  vessels  are  ligated  in  one  or  two  stages, 
in  the  latter  case  with  an  interval  of  ten  days  or  more  between.  In  cases 
of  moderate  severity  primary  partial  thyroidectomy,  with  or  without 
ligation  of  the  superior  vessels  of  the  other  lobe,  may  be  performed. 

The  subsequent  steps  in  all  of  the  three  varieties  are  determined 
by  the  course  of  the  disease,  condition  of  the  patient,  and  the  size  and 
condition  of  the  thyroid : 

In  early  and  mild  cases,  if  symptoms  persist  or  recur,  the  larger 


408  INJURIES  AND  DISEASES  OF  FACE  AND  NECK 

lobe  should  be  excised  or  one  of  the  inferior  thyroid  arteries  may  be 
ligated,  reserving  excision  for  a  subsequent  operation. 

In  severe  cases  partial  thyroidectomy  is  performed  as  soon  as 
sufficient  improvement  has  occurred  after  the  first  or  second  ligation 
to  warrant  the  operative  risk. 

In  any  of  the  varieties,  if  excision  is  followed  by  persistence  of  or 
recurrence  of  the  symptoms,  resection  of  the  second  lobe  or  a  fourth 
ligation  is  indicated.  The  latter,  however,  should  be  performed  only 
after  a  sufficient  time  has  elapsed  to  allow  some  collateral  circulation 
to  be  established. 

Partial  thyroidectomy  and  excision,  as  used  above,  imply  in  general 
removal  of  one  lobe  and  the  isthmus.  In  the  unilateral  type  of  lesion 
this  should  always  be  the  rule.  In  the  bilateral  type  a  similar  amount 
usually  should  be  removed  and  resection  of  the  second  lobe  reserved 
for  a  subsequent  operation;  but  if  both  lobes  are  large  and  the  condition 
of  the  patient  good,  excision  of  one  lobe  and  resection  of  the  other  is 
sometimes  justifiable  at  a  single  operation. 

Anesthesia. — For  most  ligations,  especially  of  the  superior  vessels, 
local  anesthesia  or  nitrous  oxide  and  oxygen  is  applicable;  for  thyroid- 
ectomy, general  anesthesia  is  advisable. 

A  preliminary  dose  of  morphin  (grain  |)  and  atropin  (gr.  -j4-o) 
should  be  given  about  one  hour  before  the  operation.  It  is  essential 
that  the  anesthesia  should  be  administered  with  extreme  care  and 
should  be  light.  Crile  has  attempted  to  meet  all  the  indications  by 
the  employment  of  anoci-association,  the  principle  of  which  is  said 
to  be  the  exclusion  of  all  harmful  stimuli. 

Postoperative  Results. — The  mortality  from  the  operative  treatment 
of  Graves'  disease  is  about  4  per  cent,  or  less  (Mayo,  Kocher,  and 
others).  The  chief  cause  of  operative  death  is  status  lymphaticus; 
the  chief  causes  of  postoperative  death  are  acute  toxemia  and 
pneumonia. 

Acute  toxemia  is  of  uncertain  etiology.  It  has  been  referred  both 
to  the  entrance  into  the  circulation  of  hypertoxic  thyroid  pioducts 
in  the  course  of  the  work  upon  the  gland  or  subsequently  from  wound 
absorption  (thyreotoxic  theory),  and  also  to  a  hyperstimulation  of  the 
vasomotor  and  trophic  nerves  of  the  region  (nervous  theory).  The 
chief  symptoms  are  extreme  tachycardia,  violent  excitement  and 
fever.  This  toxemia  is  said  to  be  present  to  a  mild  degree  in  about 
two  thirds  of  the  cases.  In  severe  cases  it  may  be  fatal  through  heart 
failure  within  two  days,  but  as  a  rule  it  subsides  in  two  or  three  days. 

Functional  End  Results. — Kocher  is  of  the  opinion  that  in  Graves' 
disease  operations  on  the  thyroid,  when  properly  performed,  almost 
invariably  lead  to  an  improvement  or  cure.  C.  H.  Mayo,  in  1912, 
gave  75  per  cent,  as  the  estimated  proportion  of  cures,  that  is,  "restored 
to  usefulness,  resuming  former  occupations,  and  nearly  free  from  all 
former  symptoms."  Some  exophthalmus,  occasional  tachycardia, 
and  relapses  of  nervousness  appear  to  have  persisted  in  some  of  these. 


TECH  NIC  OF  OPERATIONS  FOR  GOITRE  409 

TECHNIC  OF  OPERATIONS  FOR  GOITRE. 

General  precautions  include  avoidance  of  trauma  to  the  recurrent 
laryngeal  nerves,  preservation  of  the  parathyroids  to  avoid  tetany, 
and  preservation  of  sufficient  thyroid  to  avoid  myxedema. 

Excision  or  Extirpation  of  one  Lobe  or  one  Lobe  and  Isthmus. — The 
Kocher  collar  incision  should  be  used  as  routine.  It  is  transverse 
with  slight  curve,  the  concavity  being  upward,  and  should  correspond 
as  closely  as  possible  to  a  natural  fold  or  crease  of  the  skin.  The  best 
cosmetic  effect  is  obtained  by  a  low  incision  about  2  to  3  cm.  above 
the  suprasternal  notch.  The  original  incision  is  carried  through  the 
skin,  platysma  and  the  deep  fascia  to  the  depressor  muscles  of  the 
hyoid,  thus  cutting  the  anterior  jugular  veins.  The  upper  flap  is 
freed,  chiefly  by  blunt  dissection  to  approximately  the  upper  part  of 
the  thyroid  cartilage.  In  general,  the  sternohyoid,  sternothyroid 
and  omohyoid  on  the  side  to  be  removed  should  be  cut.  The  muscles 
are  divided  between  clamps,  the  line  of  division  being  high  so  as  to 
avoid  their  nerve  supply.  The  muscles  are  easily  stripped  free  and 
the  lobe  exposed.  The  surgical  capsule  is  opened  along  its  lateral 
aspect;  the  upper  pole  is  grasped  and  lifted  forward  and  the  superior 
thyroid  vessels  ligated  and  cut  with  extreme  care,  since  secondary 
hemorrhage  is  said  to  be  due  most  often  to  improper  ligation  of  these 
vessels.  The  upper  pole  is  now  dislocated  forward  and  drawn  mesially 
by  an  assistant.  The  tissues  are  bluntly  dissected  or  wiped  off  the 
posterior  surface  as  the  gland  is  lifted.  The  dissection  should  be  carried 
as  close  as  possible  to  the  true  capsule  of  the  gland,  and  independent 
small  bits  of  tissue  should  be  sought  for,  stripped  from  the  thyroid, 
and  left  uninjured.  The  branches  of  the  inferior  thyroid  artery  are 
clamped  as  they  enter  the  gland  substance,  the  blood  supply  of  the 
parathyroids  being  better  insured  by  this  method  (Halsted).  The 
isthmus  should  be  freed  from  the  trachea  and  crushed  with  a  clamp 
close  to  the  other  lobe,  and  the  lobe  and  isthmus  removed.  An  over- 
hand stitch  is  then  run  through  the  cut  edge  surrounding  the  clamp; 
it  is  tightened  and  tied  after  the  clamp  is  removed.  The  divided 
muscles  are  united  and  a  drain  is  inserted  through  a  punctured  wound. 
Complete  and  careful  closure  of  the  platysma  and  deep  fascia  is  essential 
for  a  satisfactory  scar.  The  skin  is  closed  with  a  subcutaneous  catgut 
stitch. 

Resection. — The  collar  incision  is  placed  according  to  the  plan  of 
resection,  depending  upon  the  size  and  situation  of  the  part  to  be 
removed.  The  following  resections  may  be  done:  superior  lobe, 
inferior  lobe,  isthmus,  wedge-shape  vertical  resection  from  one  or 
both  lobes. 

Ligation  of  Superior  Thyroid  Artery. — A  transverse  incision  correspond- 
ing to  a  natural  fold  or  crease  of  the  skin  is  placed  in  general  on  a 
level  with  the  middle  of  the  thyroid  cartilage.  The  anterior  border 
of  the  sternomastoid  is  freed  and  retracted  laterally;  the  omohyoid 


410  INJURIES  AND  DISEASES  OF  FACE  AND  NECK 

is  drawn  mesially.  The  upper  pole  and  vessels  are  exposed.  A  liga- 
ture of  chromic  catgut  is  applied  to  the  vessels  close  to  or  including 
the  pole.     Drainage  is  unnecessary. 

Ligation  of  Inferior  Thyroid. — A  transverse  incision  is  employed 
from  2  to  3  cm.  above  the  clavicle,  extending  from  the  midline  outward 
well  over  the  body  of  the  sternomastoid  muscle.  The  edge  of  the 
sternomastoid  is  freed  and  retracted  outward,  the  sternothyroid 
retracted  inward  and  the  mesial  aspect  of  the  carotid  sheath  exposed. 
The  thyroid  artery  lies  on  a  plane  a  trifle  deeper  than  the  common 
carotid.  Some  surgeons,  approach  the  artery  by  an  incision  along 
the  posterior  border  of  the  sternomastoid. 

Enucleation. — The  part  containing  the  nodule  or  nodules  is  freely 
exposed  by  a  transverse  incision.  Retraction  or  section  of  the  depres- 
sors of  the  hyoid  is  elected  according  to  the  requirements  of  the  case. 
The  true  capsule  and  tissue  of  the  thyroid  overlying  the  nodule  are 
incised  until  the  nodule  is  reached  and  the  nodule  is  carefully  shelled 
out  with  an  enucleator  or  finger.  Deep  mattress  sutures  of  catgut 
are  then  inserted  to  approximate  the  sides  of  the  space.  The  method 
is  adapted  only  to  nodular  or  cystic  goitres,  never  to  exophthalmic 
goitre. 

Lingual  Thyroid  (Lingual  Goitre). — Thyroid  tissue  of  normal  or 
pathological  structure  occasionally  occurs  in  the  posterior  third  of  the 
tongue.  It  may  represent  an  accessory  thyroid  or  a  misplaced  gland 
which  has  developed  in  a  high  position  as  a  result  of  an  undescended 
stalk.  Removal  of  the  tissue  is  indicated  if  there  is  discomfort,  sudden 
or  rapid  increase  in  size,  interference  with  deglutition,  respiration  or 
speech.  Operation:  The  growth  may  be  removed  from  within  the 
mouth  or  from  beneath  the  chin.  The  latter  appears  to  be  rather 
more  satisfactory  by  reason  of  easier  exposure  and  greater  facility 
in  the  control  of  hemorrhage. 

Intrathoracic  Goitres. — These  may  be  solid  or  cystic.  Pressure  symp- 
toms when  they  have  begun  increase  slowly  but  progressively,  and  are 
likely  to  reach  a  serious  degree  of  dyspnea  by  reason  of  the  confined 
position  of  the  growth  rather  than  its  size.  Operation  should  be  per- 
formed as  soon  as  the  condition  is  recognized  in  order  to  relieve  or 
avoid  severe  pressure  symptoms.  On  account  of  the  inaccessibility 
of  the  nodules,  complete  extracapsular  removal  frequently  cannot  be 
carried  out  with  safety.  Under  such  conditions  solid  growths  should 
be  opened  and  their  contents  enucleated;  a  cyst  should  be  incised, 
its  wall  sutured  to  the  skin  and  drainage  introduced.  These  procedures 
relieve  pressure  symptoms  immediately. 

Inflammation  of  Thyroid. — An  acute  inflammation  may  occur  in  a 
normal  or  goitrous  gland.  The  former  is  known  as  thyroiditis,  the  latter 
as  strumitis.  The  condition  may  occur  with  no  apparent  exciting 
cause,  but  more  often  it  is  a  sequel  to  one  of  the  acute  exanthemata  or 
occurs  in  the  course  of  an  acute  febrile  disease.  In  acute  inflammations 
of  the  thyroid  both  sides  are  usually  affected,  but  one  side  more  than 


DEFICIENCY  OF  THYROID  SECRETION  411 

the  other.  The  process  may  result  in  resolution,  suppuration  or 
gangrene. 

Symptoms. — The  symptoms  vary  according  to  whether  the  thyroiditis 
is  the  primary  affection  or  occurs  in  the  course  of  some  disease.  The 
onset  is  usually  acute  with  fever;  the  local  physical  signs  of  acute 
inflammation  are  present,  but  fluctuation  is  usually  difficult  to  elicit, 
as  the  pus  is  deeply  situated. 

Treatment. — Prior  to  suppuration,  thyroiditis  should  be  treated  by 
wet  dressing,  ice-bag,  etc.,  with  appropriate  treatment  of  the  probable 
etiological  factor.  Suppuration  demands  immediate  incision  and 
drainage. 

MALIGNANT  GROWTHS  OF  THE  THYROID. 

Malignant  growths  of  the  thyroid  gland  are  rare.  They  usually 
develop  in  a  goitrous  gland,  but  occasionally  originate  in  a  normal 
gland.     Carcinoma  and  sarcoma  occur;  carcinoma  is  the  more  frequent. 

The  patient  is  usually  over  forty  years  of  age  both  in  carcinoma 
and  sarcoma  of  the  thyroid;  the  thyroid,  which  is,  as  a  rule,  the  seat 
of  a  goitre,  increases  in  size  suddenly  and  rapidly,  is  nodular,  usually 
hard,  and  becomes  painful.  Paralysis  of  a  recurrent  laryngeal  nerve 
is  relatively  frequent.  The  neighboring  lymph  nodes  become  enlarged, 
but  this  feature  offers  little  aid  in  diagnosis  since  the  character  of  the 
thyroid  tumor  is  usually  recognized  before  they  have  enlarged;  more- 
over, the  nodes  first  involved  are  frequently  inaccessible,  lying  deep, 
either  at  the  root  of  the  neck  or  within  the  mediastinum.  Metastases 
in  the  bones  may  be  the  first  sign  of  a  malignant  growth  of  the  thyroid. 

The  success  of  treatment  depends  upon  early  diagnosis  and  early 
operation.  Some  surgeons  recommend  complete  thyroidectomy, 
but  the  majority  consider  that  complete  extirpation  of  the  gland 
is  rarely  desirable,  because  if  both  lobes  are  involved  the  trachea  is 
usually  so  firmly  attached  to  the  tumor  that  it  cannot  be  satisfactorily 
removed.  Further,  unless  both  lobes  are  involved  a  portion  of  the 
thyroid  should  be  left  in  order  to  avoid  hypothyroidism.  Extensive 
involvement  of  adjacent  structures,  such  as  the  great  vessels,  esopha- 
gus, trachea,  larynx  or  pharynx  and  extension  into  the  thorax  contra- 
indicate  operation. 

The  results  of  operations  are  relatively  good,  according  to  Kocher, 
if  the  growth  is  limited  to  one  lobe,  if  the  capsule  has  not  been  pene- 
trated, and  if  there  is  no  evidence  of  lymphatic  or  other  metastases. 

DEFICIENCY  OF  THYROID  SECRETION. 

It  has  been  shown  by  animal  experimentation  and  observations  on 
man  that  cachexia  strumipriva  or  operative  myxedema,  which  is  a 
disturbance  of  metabolism,  is  due  to  a  deficiency  of  functionating 
thyroid  tissue.  The  condition  develops  slowly  after  operation  and 
begins  with  lassitude,  weakness,  coldness  and  chilliness  of  the  body. 


412  INJURIES  AND  DISEASES  OF  FACE  AND  NECK 

The  patient  later  shows  diminution  of  mental  facilities,  slowness  of 
speech  and  slowness  of  thought.  The  skin  becomes  dry,  white  and 
thick;  there  is  a  falling  of  the  hair;  there  may  be  broadening  of  the 
features  with  expressionless  appearance,  thick  nose,  coarse  lips,  puffy 
eyelids;  the  hands  and  feet  become  coarse  and  thick,  that  is,  "spade- 
like."     In  young  patients  growth  is  arrested  to  a  marked  degree. 

Treatment. — Treatment  consists  in  the  administration  of  thyroid 
extract.  Most  cases  can  be  kept  in  relatively  good  condition  by  this 
means.  Care  should  be  exercised,  however,  lest  the  dosage  be  too 
large  and  toxic  symptoms  occur. 

Cretinism. — Cretinism,  which  is  due  to  congenital  absence  or 
atrophy  of  the  thyroid,  is  of  some  surgical  interest  by  reason  of  the 
fact  that  efforts  have  been  made  to  correct  the  thyroid  deficiency 
by  thyroid  grafting,  but  the  result  have  not  been  very  encouraging, 
although  Payr  reported  a  case  which  was  benefited  by  grafting. 

THE  PARATHYROID  GLANDS. 

The  parathyroids  were  first  described  in  1880  by  Sandstroem, 
but  no  physiological  significance  was  attached  to  these  structures 
until  1891  when  Gley  demonstrated  their  relationship  to  tetany. 

Tetany. — Experimental  studies  indicate  that  complete  removal  of 
parathyroid  tissue  results  in  fatal  tetany;  that  milder  degrees  of 
tetany  may  result  from  partial  removal  of  the  parathyroids;  that  two 
of  the  organs,  possibly  less,  are  sufficient  for  the  prevention  of  tetany. 
The  hypothesis  has  been  advanced  that  the  parathyroids  have  an 
antitoxic  action,  the  suppression  of  which  results  in  the  tetany  reaction. 
MacCallum  inclines  to  the  belief  that  tetany  is  closely  dependent 
upon  a  disturbance  of  the  calcium  content  of  the  blood.  No  constant 
lesions  have  been  demonstrated  in  the  nervous  system. 

That  tetany  following  goitre  operation  is  due  to  the  removal  of  the 
parathyroid  glandules  seems  to  have  been  proved  not  only  by  a  long 
series  of  experiments  upon  animals,  but  likewise  by  the  significant 
findings  of  Erdheim,  Pineles,  and  others  in  man. 

The  occurrence,  intensity  and  course  of  postoperative  tetany 
in  man  are  apparently  dependent  upon  the  amount  and  functional 
usefulness  of  the  parathyroid  tissue  that  is  left  (Guleke). 

Tetania,  or  tetany  parathyreopriva,  is  characterized  by  intermittent 
tonic  spasms  of  the  voluntary  muscles,  those  of  the  extremities  being 
most  affected.  Pain  is  a  frequent  concomitant  of  the  spasms.  The 
onset  of  an  attack  is,  as  a  rule,  about  one  to  three  days  after  the  opera- 
tion. The  duration  of  an  attack  may  not  exceed  a  few  minutes;  or 
the  attack  may  last  for  a  number  of  hours.  In  addition  to  the  acute 
manifestations  of  tetany,  chronic  changes  may  develop. 

Certain  Signs  or  Tests  are  of  Considerable  Value  as  an  Aid  to  Diagnosis. 
— Erb's  test  consists  in  marked  increase  of  irritability  to  the  galvanic 
current,  especially  in  the  ulnar  nerves.     Erb's  test  is  undoubtedly 


THE  PARATHYROID  GLANDS 


413 


the  most  sensitive,  reliable  and  accurate  for  tetany.  It  should  always 
•be  used  in  a  suspected  case. 

Trousseau's  phenomenon  consists  in  the  occurrence  of  a  tetanic 
spasm  in  a  limb,  as  the  result  of  compression  of  its  main  nerve  trunks. 

Chvostek's  symptom  or  facial  phenomenon  is  evidenced  by  short 
twitchings  which  can  be  elicited  in  tetanic  patients  by  gently  tapping 
over  the  area  of  distribution  of  the  facial  nerve. 

The  Leg  Phenomenon  (Beinphanomen,  Schlesinger's  Sign,  Pool's 
Phenomenon). — Contractures  are  caused  by  putting  the  sciatic  nerve 
upon  the  stretch. 

The  Arm  Test. — Contractures  are  caused  by  putting  the  nerves 
of  the  brachial  plexus  on  the  stretch  by  elevating  the  arm  above  the 
head  with  the  foreann  extended  (extreme  abduction). 

Course. — The  course  of  tetany  following  thyroidectomy  has  been 
divided  by  Frankl  Hochwart  into  three  classes:  First,  cases  character- 
ized by  onset  soon  after  operation,  severe  course,  and  fatal  outcome; 


Fig.  203. — Leg  phenomena  in  tetany,  showing  contractures  of  muscles  of  calf  and 
plantar  flexion  of  foot. 

second,  cases  in  which  the  symptoms  appear  soon  after  the  operation 
but  subside  after  a  variable  time  and  are  followed  by  recovery;  third, 
cases  in  which  the  patients  live  but  present  the  manifestations  of 
chronic  tetany.  Further,  there  may  occur  "latent  tetany"  with  no 
muscular  spasms  but  with  positive  Chvostek's  phenomena  and  other 
kindred  signs.  Moreover,  after  the  spasmodic  attacks  have  ceased, 
recurrences  may  take  place.  Of  the  cases  compiled  by  Guleke,  25 
per  cent,  died,  and  17  per  cent,  developed  a  chronic  or  markedly 
recurrent  tetany. 

Treatment. — As  soon  as  symptoms  of  tetany  are  noticed  calcium 
lactate  should  be  administered  preferably  intravenously,  and  repeated 
as  indicated;  parathyroid  nucleoproteid  should  be  given  continuously. 
Parathyroid  implantation  is  indicated  when  medicinal  treatment,  seems 
of  no  avail  or  when  the  symptoms  persist  for  a  sufficient  time  to 
make  it  probable  that  spontaneous  cure  will  not  take  place. 

From  experimental  evidence  it  is  probable  that  autoplastic  para- 


414  IX JURIES  AND  DISEASES  OF  FACE  AXD  NECK 

thyroid  grafts  may  be  successful  morphologically  and  functionally, 
and  possibly  may  even  functionate  permanently;  on  the  other  hand 
with  homoplastic  parathyroid  grafts  permanent  functionating  results 
have  not  been  proved.  In  man  homoplastic  parathyroid  implanta- 
tions have  been  performed  in  about  thirteen  cases.  The  results  in 
these  cases  were  not  conclusive,  though  in  several  there  was  a  strong 
probability  that  the  graft  proved  efficient.  Three  interpretations  are 
possible  if  the  symptoms  subside  after  parathyroid  implantation: 
First,  that  the  graft  exerted  no  influence;  second,  that  the  graft  exerted 
a  temporary  effect;  and  third,  that  the  transplanted  parathyroid 
was  permanently  effective  as  a  functionating  graft. 

In  view  of  the  uncertain  status  of  all  proposed  methods  of  treatment, 
the  importance  of  prophylaxis  is  self-evident.  The  operator  must 
attempt  to  leave  these  bodies  in  situ  with  blood  supply  unimpaired. 

In  order  to  preserve  the  parathyroids  in  the  removal  of  a  thyroid  lobe 
the  dissection  of  the  thyroid  gland  must  be  carried  as  close  as  possible 
to  the  true  capsule  of  the  organ,  and  small  independent  bits  of  tissue 
should  be  sought  for  in  this  situation,  stripped  from  the  thyroid,  and 
left  uninjured.  By  this  procedure  the  removal  of  the  lobe  is  made 
from  within  the  surgical  capsule,  that  is,  intracapsular.  It  is  even 
safer,  however,  to  leave  a  small  layer  of  the  posterior  part  of  the  lobe 
of  the  thyroid,  especially  in  the  region  of  the  inferior  thyroid  artery. 
The  practise  of  leaving  the  isthmus  only  is  a  dangerous  procedure. 

In  order  to  preserve  the  blood  supply  of  the  parathyroids  extreme 
care  should  be  exercised  in  ligating  the  inferior  thyroid  artery.  One 
of  two  procedures  should  be  adopted.  Either  the  branches  should  be 
clamped  as  they  enter  the  gland — "ultra  ligation"  (Halsted) — or  the 
main  stem  should  be  ligated  well  outside  of  the  surgical  capsule,  that 
is,  a  considerable  distance  from  the  probable  site  of  the  inferior  para- 
thyroid so  as  not  to  interfere  with  anastomoses.  Care  should  be  taken 
to  avoid  including  in  a  ligature  or  clamp  the  inferior  parathyroid 
which  frequently  lies  in  close  relation  to  the  inferior  thyroid  artery. 

Acute  infections  of  the  parathyroids  occur  rarely;  the  parathyroids 
are  said  to  be  involved  at  times  in  syphilis  and  tuberculosis. 

Cysts  and  tumors  have  been  reported.  Of  the  latter,  parastruma 
(Langhans)  constitutes  the  most  important  variety.  Microscopically 
the  tumor  is  suggestive  of  parathyroid  tissue.  It  may  occur  either 
in  the  usual  situations  of  the  normal  parathyroids  close  to  the  thyroid, 
or  within  the  thyroid,  or  at  a  distance  from  the  thyroid,  for  instance 
in  the  mediastinum  or  carotid  region.  Guleke  estimates  the  reported 
cases  as  about  forty.  The  tumor  tends  to  invade  adjacent  structures 
and  to  give  rise  to  metastasis. 

HARE-LIP  AND  CLEFT  PALATE. 

The  separation  of  the  mouth  from  the  nasal  cavities  is  accomplished 
in  the  early  embryo  by  the  improper  fusion  of  the  first  branchial  arches 


HARE-LIP  AND  CLEFT  PALATE 


II.-) 


with  the  intermaxillary  bone  in  the  median  line  to  form  the  lips, 
alveolus,  hard  and  soft  palate.     The  failure  of  fusion  may  be  complete 


Fig.  204.— Single  hare-lip. 

or  the  defect  may  only  affect  the  anterior  or  posterior  part  of  this 
septum;  if  anterior  alone  the  deformity  is  a  hare-lip,  unilateral  or 


Fig.  205. — Double  hare-lip. 

bilateral,  incomplete  or  complete,  i.  e.,  extending  into  the  nose  (Figs. 
204  and  205). 


416  INJURIES  AND  DISEASES  OF  FACE  AND  NECK 

The  hare-lip  of  any  grade  may  be  accompanied  by  a  variable  grade 
of  defect  in  the  alveolus.  When  the  cleft  begins  posteriorly  there  may 
be  a  cleft  in  the  soft  palate  alone  or  simply  a  bifurcated  uvula,  or  the 
cleft  extends  to  a  variable  distance  through  the  hard  palate  or  is 
complete.  When  the  cleft  in  the  lip  is  complete  and  bilateral  the 
intermaxillary  bone  is  likely  to  be  displaced  anteriorly  out  of  the  dental 
arch  and  may  look  upward  instead  of  forward;  if  the  cleft  is  unilateral 
the  intermaxillary  bone  is  rotated  on  its  vertical  axis. 

The  middle  and  perhaps  the  lateral  incisor  teeth  are  developed 
from  this  bone  hence  its  preservation  under  all  circumstances  is 
important,  though  many  have  been  tempted  to  remove  it  and  thus  rid 
the  patient  at  once  of  its  most  conspicuous  deformity. 

Hare-lip  is  an  unsightly  deformity  of  the  nose  as  well  as  lip;  it 
interferes  with  sucking,  with  speech  and  to  some  extent  with  nasal 
breathing.  We  operate  mainly  with  the  idea  of  improving  the  patient's 
appearance  but  also  with  reference  to  nutrition  and  speech. 


Fiu.  206. — Drawing  from  cast  of  jaw  Fi<;.  207. — Same,  seven  months  later; 

in   child  of  six   weeks  at   time  of   chilo-  maxilla;    have    grown    but    clefts    have 

plasty.  narrowed. 

Cleft  palate  leads  to  catarrhal  conditions  of  the  respiratory  tract 
and  seriously  impairs  speech.  In  operating,  restoration  of  function 
should  not  be  lost  sight  of  in  an  effort  to  construct  a  mechanical 
diaphragm.  We  aim  to  establish  nasal  breathing,  to  improve  speech 
and  construct  such  a  dental  arch  as  will  give  a  good  occlusion  of  the 
upper  with  the  lower  teeth.  The  amount  of  development  of  the  jaws 
during  the  years  of  growth  and  after  operation  will  depend  largely 
on  the  establishment  of  function,  i.  e.,  chewing  and  nasal  breathing. 

CJdloplasty  is  an  operation  for  hare-lip,  staphylorrhaphy,  one  for 
closure  of  the  soft  palate  and  uranoplasty,  one  for  the  closure  of  the 
hard  palate.  Chiloplasty  can  safely  and  wisely  be  done  in  the  early 
weeks  of  life  and  should  not  be  postponed  until  teething.  One  makes  an 
exception  of  the  marasmatic  infants  that  remain  at  their  birth  weight, 
— these  are  rather  numerous  and  the  mortality  of  hare-lip  and  cleft 
palate  cases  is  about  50  per  cent,  in  their  first  year.  A  chiloplasty 
(Figs.  206  and  207)  is  very  efficient  in  the  first  three  months  in  restor- 


HARE  LIP   AND  ('LEFT   I' A  LATE 


417 


ing  the  intermaxillary  hone  to  its  place  in  the  dental  arch  and  narrow- 
ing the  defects  in  the  alveolus  and  hard  palate.  It  is  little  less  than 
marvelous  to  see  a  gap  in  the  alveolus  a  third  of  an  inch  wide  close  in  a 
couple  of  months  after  a  closure  of  the  lip,  or  to  see  an  upturned  inter- 
maxillary hone  rotate  through  an  arc  of  almost  90  degrees  into  the 
dental  arch  from  this  operation  alone. 


Fig.  208.- 


-Brown's  wire  suture  in  place.     The  dot-ted  line  indicates  the  extent  of  under- 
cutting of  the  cheek. 


Chiloplasty. — Best  results  are  obtained  and  Jess  anesthetic  needed 
in  the  first  weeks  of  life.  Ether  is  preferable  to  chloroform  in  hare-lip 
and  cleft  palate  cases.  The  child  should  not  nurse  for  two  hours 
before  operation  but  can  immediately  after.  Avoid  any  method  of 
operating  that  sacrifices  more  than  a  minimum  of  tissue,  but  never 
spare  any  of  the  vermilion  border  of  the  cleft  itself,  for  this  will  leave 
a  permanent  colored  scar.  Seek  to  have  the  lip  a  little  longer  at  the 
point  of  suture  than  elsewhere  to  compensate  subsequent  contraction. 
There  is  an  advantage  in  having  a  broken  line  scar  to  having  a  straight 


Ci^_^t) 


Fig.  209. — Mirault's  operation. 


vertical  one.  Tension  should  be  relieved  by  an  extensive  separation 
(Fig.  208)  of  the  cheek  and  margin  of  the  nostril  from  the  maxillary 
bone.  The  most  difficult  part  of  the  operation  is  the  formation  of  a 
nostril  that  will  not  widen  or  flatten. 

The  Operation. — In  the  simplest  case,  an  incomplete  hare-lip  with 
sides  of  equal  length,  the  cleft  is  denuded  by  curved  incisions  and 
27 


418 


INJURIES  AND  DISEASES  OF  FACE  AND  NECK 


the  sides  of  the  cleft  sutured  with  silk,  but  when,  as  is  usually  the  case, 
the  sides  of  the  cleft  are  of  unequal  length  the  operation  that  goes 
by  the  name  of  Mirault  (Fig.  209)  and  others  is  usually  selected.  It 
is  simple  and  efficient.  Simon's  operation  (Figs.  210  and  211),  except 
that  it  sacrifices  more  than  a  minimum  of  tissue,  is  a  good  one.  The 
quadrilateral  piece  of  Simon  holds  its  position  at  the  margin  of  the  lip 
better  than  the  pointed  one  of  Mirault.  In  both  the  vermilion  border 
is  left  as  a  continuous  line.     If  the  cleft  is  complete,  after  freeing  the 


Gr^vi) 


Figs.  210  and  211. — Simon's  operation. 

cheeks,  the  nostril  is  reconstructed  before  the  denudation  for  the  lip 
is  made. 

Transverse  scars  on  the  lip  are  to  be  avoided  by  putting  the  sutures 
close  to  the  margins  and  relieving  the  tension  on  them :  (a)  By  freeing 
the  cheek  (Fig.  208),  (6)  by  Lane's  suture,  or  (c)  Brown's  wire  suture 
through  the  nostril.  Lane  suture  (Figs.  212  and  213)  perforates  the 
skin  but  the  needle  is  introduced  through  the  same  hole  and  when 
tied  on  the  inside  of  the  mouth  leaves  no  sign  on  the  skin  surface. 
Brown's  wire  suture  (Fig.  208)  passes  through  the  septum  of  the  nose, 


Q 


£ 


Figs.  212  and  213. — Lane's  tension  relieving  suture.    Tied  in  the  mouth. 

crosses  the  nostril  and  emerges  at  the  crease  at  the  side  of  the  ala 
nasi.  These  sutures  relieve  the  tension  as  well  as  the  now  abandoned 
hare-lip  pin  and  obviate  its  scar. 

No  dressing  for  the  wound  is  employed,  but  it  is  allowed  to  heal 
under  a  scab. 

Figs.  214  and  215  illustrate  the  usual  method  of  operating  in  double 
hare-lip.  The  tension  is  usually  great  and  the  lip  remains  tightly 
drawn   over  the  maxilla  and  is  too  long.     Brown's  method   (Figs. 


11  ARE-LIP   AND  (LEFT   PALATE 


419 


216  and  21  <  >  gives  a  shorter  and  wider  lip  and  would  be  recommended 
when  there  is  an  unusual  deficiency  of  tissue. 


Figs.  214  and  215. —  Operation  fur  complete  hare-lip. 

The  intermaxillary  hone  (Figs.  21s  and  219)  is  not  to  he  removed 
because  of  the  resulting  hideous  profile.     In  the  first  weeks  of  life  it 


Figs.  216  and  217. — Brown's  operation  for  bilateral  hare-lip. 

can  he  depressed  somewhat  with  adhesive  plaster  and  chiloplasty  will 
complete  the  reduction  as  shown  in  Figs.  206  and  207,  both  drawn 
to  the  same  scale  from  casts. 


Figs.  218  and  219. — Deformities   resulting   from  the  protrusion  of   and   absence  of   the 
intermaxillary  bone.     (From  photographs.) 

Uranoplasty  and  Staphylorrhaphy. — When  the  operation  in  an  infant 
occupies  two  to  three  hours  a  fatal  termination  may  be  confidently 
expected.     In  a  simple  case  and  with  the  facilities  for  nasal  or  pharyn- 


420 


INJURIES  AND  DISEASES  OF  FACE  AND  NECK 


geal  anesthesia  at  hand,  the  operation  should  not  exceed  an  hour. 
Most  operators  wait  until  the  child  is  between  two  and  three  years  old, 
but  should  not  defer  much  longer  because  it  is  important  to  begin 
speech  training  early.  Avoid  sacrificing  tissue,  impairment  of  blood 
supply,  and  relieve  tension. 


Fig.  220. — Brophy's  operation. 

Brophy  operates  on  the  palate  in  the  first  weeks  of  life  and  seeks  to 
narrow  the  cleft  by  forcing  the  maxilla?  together  with  the  aid  of  wire 
sutures  passed  through  the  entire  thickness  of  the  jaws.  The  sutures 
are  passed  through  lead  plates  at  either  side  and  are  then  twisted 


£t^> 


Fig.  221. — Lane's  operation  showing  incisions. 


FlG.  222. — Same  with  flaps  sutured. 


together  as  shown  in  (Fig.  220)  to  make  pressure.  The  lip  is  closed 
at  a  later  date.  This  method  dot's  not  grow  in  favor.  In  the  newborn, 
to  avoid  perforating  tooth  follicles,  the  sutures  must  be  on  the  level 
of  the  floor  of  the  orbit;  the  nares  are  so  compressed  as  to  preclude 


HARE-LI V   AM)  (LEFT   PALATE 


421 


nasal  breathing  and  the  dental  arch  in  later  life  is  the  despair  of  an 
orthodontist.     By  Lane's  method    Figs.  221  and  -'-1)  a  very  wide  defect 

can  be  closed.  He  makes  a  mucoperiosteal  Hap  from  one  side  and  slides 
it  under  a  Hap  on  the  other  side  of  the  cleft;  these  are  spoken  of  a>  the 
hinge  and  pocket  flaps.  Before  the  teeth  are  erupted  the  hinge  flap 
may  be  made  very  wide,  extending  laterally  over  the  alveolus  as  it 
does  in  Fig.  22 1  in  the  part  of  the  flap  behind  the  last  tooth.  Good 
articulation  requires  good  muscular  control  of  the  soft  palate  and  in 
this  operation  there  is  so  much  dissection  of  the  parts  and  cicatrization 
afterward  that  speech  may  he  little  improved. 

Langenbeck's  Operation.-- This  is  the  operation  (Fig.  223)  usually 
employed  and  the  one  least  damaging  to  the  parts  concerned. 

1.  The  inner  margins  of  the  cleft  in  the  hard  and  soft  palate  are 
denuded  so  as  to  give  a  good  raw  surface  for  suturing. 


Fig.  223. — Langenbeck's  operation. 


2.  With  an  elevator  a  mucoperiosteal  flap  is  raised  from  the  whole 
surface  of  the  bony  palate,  care  being  taken  to  have  the  uninjured 
palatine  arteries  included  in  the  flaps. 

3.  The  soft  palate  is  separated  from  the  posterior  margin  of  the 
hard  palate. 

4.  If  the  palate  is  of  the  Gothic  arch  variety  it  may  now  be  sutured. 
Usually,  however,  this  would  be  impossible  without  too  great  tension, 
so  incisions  are  made  parallel  to  the  edges  of  the  cleft  just  internal  to 
the  alveolar  margin  through  the  mucoperiosteal  flaps. 

5.  The  edges  of  the  cleft  are  sutured  with  silk,  silkworm  gut,  or 
linen.  At  times  silver-wire  sutures  are  passed  through  lead  plates  to 
equalize  the  tension  over  a  larger  area  of  the  flap  and  take  some  tension 
from  the  suture  line. 

6.  Additional  tension  relieving  incisions  may  be  made  in  the  soft 
palate  as  indicated  by  the  two  short  lines  in  Fig.  223. 


422  INJURIES  AND  DISEASES  OF  FACE  AND  NECK 

DISEASES  OF  THE  NOSE,  NASOPHARYNX,  AND  ACCESSORY 

SINUSES. 

Saddle-nose. — Depression  or  flattening  of  the  bridge  of  the  nose 
may  occur  as  a  result  of  trauma,  septal  abscess,  syphilis,  or  tuberculosis. 
Of  these,  trauma  and  syphilis  furnish  the  largest  number  of  cases. 
In  the  former,  the  injury  is  always  direct  and  results  in  a  more  or  less 
comminuted  fracture  of  the  structures  of  the  bony  framework,  particu- 
larly the  nasal  bones  and  septum. 


Fig.  224. — Syphilitic  deformity  of  the  nose. 

In  both  congenital  and  acquired  syphilis,  gumma  of  the  septum, 
with  later  ulceration  and  necrosis  of  the  bone  and  cartilages,  results  in 
a  falling  in  of  the  bridge  and  a  characteristic  turning  upward  of  the 
tip.  In  the  treatment  of  this  condition,  vigorous  antisyphilitic  measures 
should  be  employed  in  the  specific  cases,  as  long  as  any  inflammatory 
signs  are  present.  A  number  of  methods  of  overcoming  the  deformity 
have  been  suggested.  Weir  advises  the  use  of  a  celluloid  plate.  His 
method  consists  in  making  an  incision  along  the  nasofacial  sulcus, 
freely  separating  the  skin  from  the  remaining  portions  of  the  bone  and 
cartilage,  and  introducing  a  sterile  plate  of  celluloid  so  fashioned  as  to 
restore  the  proper  shape  to  the  organ.  Care  should  be  taken  to  avoid 
wounding  the  mucous  membrane  of  the  nasal  cavity.  When  the 
celluloid  plate  is  in  place  the  cutaneous  wound  is  closed,  without 


DISEASES  OF  THE  NOSE  AND  NASOPHARYNX 


123 


drainage,  with  fine  silk  sutures.  Recently  saddle-nose  and  other 
facial  deformities  due  to  loss  of  tissue  have  been  successfully  treated 
by  the  subcutaneous  injection  of  sterile  melted  paraffin,  which  elevates 
thejdepressed  scar-tissue  and  is  easily  molded  into  shape  before  it 
hardens.  Paraffin  melts  at  115°  F.,  and  should  be  introduced  by 
means  of  a  well-heated  metal  aspirating  syringe,  with  a  large  needle. 


Fig.  225. — Bone  transplantation  for  nasal  deformity.  The  central  figure  showy 
method  of  elevating  skin  and  subcutaneous  tissues;  the  insert  figure  shows  the  bone  in 
place.     (Carter.) 


The  needle  should  be  introduced  preferably  at  a  short  distance  from 
the  point  where  the  paraffin  is  to  be  deposited  and  the  injection  made 
from  above  downward  with  the  paraffin  in  a  semisolid  state.  The 
reason  for  this  is,  that  in  not  less  than  three  instances  where  these 
directions  have  not  been  carried  out  the  operation  has  been  followed 
by  embolism  of  the  central  artery  of  the  retina. 


424 


INJURIES  AND   DISEASES  OF  FACE  AND  NECK 


Carter  makes  an  incision  at  the  root  of  the  nose — separates  the 
skin  and  subcutaneous  tissues  from  the  deeper  structures,  and  intro- 
duces an  autogenous  bone  graft  taken  from  a  rib.  The  inferior  extrem- 
ity of  this  bone  graft  is  pushed  downward  to  a  point  near  the  tip  of  the 
nose,  and  its  upper  extremity  firmly  anchored  to  the  frontal  bone, 
by  placing  it  in  a  small  pocket  made  by  raising  the  frontal  periostium. 
The  cutaneous  wound  is  carefully  sutured  without  drainage.  (Fig. 
225). 

Partial  or  Complete  Destruction  of  the  Nose. — Partial  or  complete 
destruction  of  the  nose  may  result  from  malignant  disease,  syphilis, 
lupus,  or  trauma.  It  is  sometimes  remedied  by  rhinoplasty,  which 
consists  in  grafting  skin  from  some  other  portion  of  the  body  into  the 
defective  area.  The  two  methods  usually  employed  are  by  a  flap 
from  the  forehead  and  by  a  flap  from  the  forearm.  In  the  former 
method  the  diseased  tissues  of  the  nose  are  removed,  making  a  triangu- 


Fig.  226. — Rhinoplasty.     Indian  method  modified.      (Stimson.) 


lar  wound,  and  an  oval  flap  cut  from  the  forehead,  curved  downward, 
and  stitched  in  place  as  seen  in  Fig.  226.  The  colunma  is  fashioned 
from  the  lower  extremity  of  the  flap  and  the  nasal  orifices  kept  patent 
by  the  insertion  of  two  rubber  tubes.  In  the  arm  method  an  oval 
flap  is  partly  cut  from  the  forearm,  leaving  a  deep  pedicle  attached 
below.  The  arm  is  then  carried  upward  to  the  face  and  the  cut  edge 
of  the  flap  stitched  to  the  upper  margin  and  one  side  of  the  nasal 
wound.  The  arm  is  held  in  this  position  for  a  week  or  ten  days  by 
means  of  a  plaster-of-Paris  dressing.  When  union  has  taken  place, 
the  flap  is  completely  severed  from  the  arm,  cut  to  fit  the  nasal  opening, 
and  stitched  in  place.  To  overcome  the  subsequent  depression  of  the 
soft  transplant  Finney,  of  Baltimore,  has  advised  and  successfully  prac- 
tised grafting  a  finger  of  the  left  hand  in  the  nasal  defect.  Morestin 
uses  an  autogenous  bone  graft  in  the  following  manner:  A  thin 
section  of  a  rib  is  transplanted  to  the  forehead  between  the  skin  and 
occipitofrontalis  muscle  and  the  wound  of  entrance  sutured.     Later 


DISEASES  OF  THE  NOSE  AND  NASOPHARYNX 


42.") 


when  all  signs  of  reaction  have  subsided,  he  employs  the  first  operation 
described  above  and  illustrated  in  Fig.  226,  cutting  the  forehead  flap 
in  such  a  manner  as  to  include  in  its  central  portion  the  transplanted 
bone. 

Foreign  Bodies  in  the  Nose. — Buttons  and  other  foreign  bodies  are 
frequently  introduced  into  the  nose  by  young;  children.  They  give 
rise  to  pain  and  a  purulent  rhinitis.  The  child  should  be  etherized, 
cocaine  or  adrenalin  applied  to  the  mucous  membrane,  and  the  interior 
of  the  nares  thoroughly  examined  by  means  of  a  nasal  speculum  and 
head-mirror.  The  foreign  body  can  usually  be  found  and  removed 
by  forceps. 

Epistaxis. — Epistaxis,  or  bleeding  from  the  nose,  may  occur  from  a 
blow  upon  the  nose  or  other  trauma,  from  acute  congestion,  from 
violently  blowing  the  nose,  from  sneezing,  or  from  an  ulcer  of  the 
septum  or  of  the  mucous  membrane  covering  the  turbinated  bodies. 


Fig.  227. — Plugging  the  nostrils  with  Bellooq's  sound.     (Fergusson.) 

Treatment. — The  treatment  should  consists  in  rest,  cold  applications, 
or  the  use  of  astringent  sprays,  as  cocaine,  adrenalin,  antipyrin,  or 
tannin.  Park  recommends  equal  parts  of  a  10  per  cent,  solution  of 
antipyrin  and  a  10  per  cent,  solution  of  tannic  acid.  If  the  bleeding 
point  is  situated  anteriorly,  plugging  the  anterior  nares  with  cotton 
or  gauze  will  generally  arrest  the  hemorrhage.  If  this  fails,  plugging 
the  posterior  and  anterior  nares  will  give  prompt  relief.  To  accom- 
plish this,  a  soft-rubber  catheter  having  a  loop  of  silk  or  linen  thread 
tied  about  its  free  extremity,  or  a  Bellocq  canula  (Fig.  227),  armed 
with  a  similar  loop,  is  passed  through  the  nose  into  the  pharynx. 
Through  this  loop  is  passed  a  loop  of  heavy  twine,  to  which  is  attached 
a  fine-meshed  folded  sponge  or  gauze  pad.  The  loop  is  drawn  outward 
through  the  nose  and  the  sponge  drawn  snugly  into  the  posterior 


426  INJURIES  AND  DISEASES  OF  FACE  AND  NECK 

nasal  orifice.  When  this  is  secured,  a  second  plug  should  be  inserted 
into  the  anterior  orifice  and  retained  by  tying  the  two  arms  of  the 
projecting  loop.  This  should  be  allowed  to  remain  in  place  for  from 
thirty-six  to  forty-eight  hours,  after  which  it  can  be  removed  by  a 
third  strand  of  twine  which  passes  from  the  sponge  outward  through 
the  mouth . 

Inflammation  of  the  Maxillary  Antrum. — Inflammation  of  the  max- 
illary antrum  is  usually  a  sequel  of  an  acute  septic  rhinitis,  the  infection 
reaching  the  antrum  by  means  of  the  foramen  which  opens  into  the 
middle  meatus  of  the  nose;  it  results  also  from  suppurative  disease  of 
a  tooth  socket. 

Symptoms. — The  symptoms  of  the  acute  form  are  pain  and  soreness 
in  the  cheek,  with  neuralgic  pains  over  the  distribution  of  the  second 
branch  of  the  fifth  nerve,  fever,  and  tenderness  of  the  upper  teeth. 
Later,  an  abundant  purulent  discharge  may  appear  from  the  nose, 
which  gives  marked  relief  to  the  symptoms.  In  the  chronic  form — 
empyema  of  the  antrum — there  are  constant  discomfort  and  neuralgia 
of  the  face,  with  an  intermittent  nasal  discharge.  Necrosis  of  the 
thin  bony  walls  may  occur,  allowing  the  pus  to  burrow  into  the  orbit 
or  pterygomaxillary  fossa,  or  it  may  break  externallv.  When  the 
pterygomaxillary  fossa  is  invaded,  there  are  stiffness  of  the  jaw  and  a 
bulging  of  the  temporal  muscle  from  the  pus  making  its  way  upward 
behind  the  zygoma  into  the  temporal  fossa.  Occasionally  it  points 
downward  into  the  mouth  near  the  last  molar  tooth.  In  the  various 
forms  of  antral  suppuration,  as  in  other  diseases  of  this  and  the  other 
accessory  sinuses,  much  may  be  learned  by  transillumination  and  the 
study  of  a  well-taken  .r-ray  plate.  For  the  details  of  these  special 
examination  methods,  the  reader  is  referred  to  one  of  the  standard 
works  on  rhinology. 

Treatment. — The  treatment  of  the  acute  form  is  expectant.  If 
relief  does  not  occur  promptly  through  the  natural  channel,  the  cavity 
may  be  drained  by  breaking  an  opening  through  the  thin  bony  plate 
which  separates  the  antrum  from  the  inferior  meatus  of  the  nose. 
This  can  easily  be  done  by  a  pair  of  sharply  curved  forceps  introduced 
into  the  nasal  cavity  beneath  the  lower  turbinated  body  and  forcibly 
thrust  through  the  thin  septum  into  the  cavity  of  the  antrum,  then 
opening  the  forceps  and  withdrawing  them.  The  cavity  can  be 
irrigated  through  this  opening  by  means  of  a  soft-rubber  catheter  or 
curved  irrigating  tube.  In  the  chronic  cases,  in  addition  to  nasal 
drainage,  it  is  often  necessary  to  open  the  antrum  through  the  canine 
fossa,  curette  the  cavity,  and  establish  permanent  drainage.  If 
necrosis  exists,  a  large  part  of  the  anterior  wall  can  be  removed  through 
the  mouth  without  external  incision,  the  necrosed  bone  located  and 
removed,  and  the  entire  cavity  packed. 

Abscesses  of  the  pterygomaxillary  fossa  should  be  opened  above 
the  zygoma,  and  through  this  opening  a  dressing  forceps  or  other 
blunt  instrument  may  be  passed  downward  to  the  buccal  cavity, 


DISEASES  OF  THE  NOSE  AND  NASOPHARYNX 


427 


and  the  space  opened  from  below  on  this  guide.  A  drainage  tube 
is  then  carried  from  the  lower  opening  through  the  region  of  the 
abscess,  and  outward  in  the  temporal  region.  Through  this  the 
diseased  area  can  be  frequently  irrigated. 

Inflammation  of  the  Frontal  Sinus.  Inflammation  of  the  frontal 
sinus  also  results  from  extension  of  an  inflammatory  process  upward 
from  the  nose  through  the  infundibulum.  The  symptoms  are  severe 
throbbing,  supra-orbital  pain,  and  tenderness  over  the  frontal  bone. 
One  or  both  sinuses  may  be  involved.  In  neglected  cases  the  bone  is 
necrosed,  pus  may  burrow  into  the  orbit  and  cause  exophthalmos 
(Fig.  22S),  or  into  the  cranial  cavity,  giving  rise  to  meningitis  or  cere- 
bral abscess.     In  the  chronic  form  a  more  or  less  constant  headache. 


Fig.  228. — Exophthalmos  from  orbit  infection. 


limited  to  the  affected  side,  with  evidences  of  slow  septic  absorption, 
may  be  the  only  symptoms.  As  in  cases  of  empyema  of  the  antrum, 
the  presence  of  retained  pus  in  the  frontal  sinus  often  may  be  detected 
by  transillumination  or  the  .r-rays. 

Treatment. — The'  treatment  should  be  by  incision  along  the  upper 
margin  of  the  orbit  near  the  median  line,  retracting  the  superior 
margin  of  the  incision  well  upward,  and  opening  the  sinus  by  means  of  a 
chisel  and  mallet.  A  small  drainage  tube  may  be  passed  downward 
into  the  nasal  cavity  through  the  bony  canal  (which  often  must  be 
enlarged)  or  the  sinus  may  be  packed  until  the  inflammation  has  sub- 
sided, after  which  the  cutaneous  wound  may  be  allowed  to  heal. 
To  avoid  the  depressed  scar  which  so  often  follows  these  operations, 


428  INJURIES  AND  DISEASES  OF  FACE  AND  NECK 

Killian  advises  leaving  the  supra-orbital  ridge,  opening  the  cavity 
both  above  and  below  this  bony  bridge. 

When  there  is  involvement  of  the  ethmoid  or  sphenoid  cells,  these 
structures  may  be  reached  by  carrying  the  original  incision  downward 
along  the  side  of  the  nose,  chiselling  away  the  frontal  process  of  the 
superior  maxilla,  and  if  necessary,  a  portion  of  the  nasal  bone. 

TUMORS  OF  THE  NOSE  AND  NASOPHARYNX. 

Rhinophyma. — As  a  result  of  a  neglected  acne  rosacea  there  occasion- 
ally develops  an  enormous  overgrowth  of  the  sebaceous  elements  of 
the  skin,  chiefly  at  the  tip  of  the  nose,  resulting  in  great  hypertrophy 
and  dilatation  of  the  vessels. 

Treatment. — The  treatment  should  consist  in  surgical  removal  of 
the  exuberant  masses,  followed  by  skin  grafting. 

Nasal  Polypus. — These  tumors  occur  frequently,  and  are  generally 
due  to  some  chronic  suppurative  disease  of  the  ethmoid  cells  or  middle 
turbinated  body.  They  occur  as  large  or  small  oval  gelatinous 
bodies,  which  may  be  so  numerous  as  completely  to  fill  the  cavity  and 
produce  total  obstruction.  They  are  pedunculated  and  are  attached 
to  the  mucous  membrane  covering  the  two  upper  turbinates. 

Treatment. — The  treatment  should  consist  in  removal  with  the 
Jarvis  or  Bosworth  nasal  snare.  Recurrence  should  be  avoided  by 
curing  the  original  suppurative  disease. 

Nasopharyngeal  or  Fibrous  Polypus. — This  growth  is  in  reality  a 
fibrosarcoma  which  arises  from  the  periosteum  of  the  base  of  the  skull 
at  the  vault  of  the  pharynx.  Its  growth  is  at  first  slow,  and  as  it 
produces  no  symptoms  until  it  is  of  sufficient  size  to  cause  nasal 
obstruction ;  it  is  often  overlooked  in  the  beginning.  It  occurs  generally 
in  individuals  between  ten  and  twenty  years  of  age.  It  may  reach  an 
enormous  size,  invading  the  nose,  orbit,  and  antrum,  causing  great 
deformity  of  the  face  and  often  eroding  the  skull  and  involving  the 
intracranial  structures. 

Symptoms. — The  symptoms  are  generally  those  of  a  catarrhal 
affection  with  more  or  less  complete  nasal  obstruction  and  mouth- 
breathing;  later,  deformity  occurs  and  pain  from  pressure  on  neigh- 
boring structures. 

Treatment. — The  treatment  should  consist  in  early  and  complete 
excision.  If  the  growth  is  small,  this  often  can  be  accomplished  by 
a  snare  or  galvanic  ecraseur  introduced  through  the  nose  and  manip- 
ulated into  place  by  the  finger  introduced  into  the  pharynx,  or  guided 
by  means  of  the  rhinoscope.  When  the  tumor  is  larger  it  should  be 
attacked  through  an  external  incision.  By  far  the  best  procedure 
for  these  cases  is  the  Langenbeck  operation,  which  consists  in  an 
incision  from  the  root  of  the  nose  downward  in  the  nasofacial  sulcus 
to  a  point  just  below  the  ala.  This  incision  is  carried  to  the  bone, 
and  the  soft  parts,  including  the  periosteum,  are  raised  with  an  elevator 


TUMORS  OF  THE  NOSE  AND  NASOPHARYNX  429 

and  retracted.  The  nasal  bone,  the  nasal  process  of  the  superior 
maxilla,  a  part  of  the  lachrymal  bone,  and  a  part  of  the  nasal  cartilage, 
are  then  removed  with  a  chisel  and  mallet,  and  an  opening  established 
through  which  the  finger  may  easily  be  passed  to  the  upper  part  of 
the  pharynx.  Through  this  opening,  and  assisted  by  a  finger  intro- 
duced into  the  pharynx  through  the  mouth,  the  growth  can  be  accu- 
rately located,  its  pedicle  isolated  and  divided.  As  the  growth  is 
sometimes  tabulated,  it  may  be  necessary  to  divide  it  with  scissors 
or  the  knife  in  order  to  remove  it.  Considerable  bleeding  may  occur 
not  only  from  the  divided  pedicle,  but  also  from  rupture  of  secondary 
attachments.  If  these  can  be  located,  they  should  be  touched  with 
the  cautery,  or  if  necessary  the  wound  may  be  packed.  The  packing 
should  be  removed  in  forty-eight  hours  and  the  cutaneous  wound 
closed  with  silk  or  silkworm  gut.  If  the  tumor  is  too  large  to  be 
removed  by  this  method,  partial  or  complete  excision  of  the  superior 
maxilla  may  be  necessary.  If  for  any  reason  operation  is  contra- 
indicated,  Harmon  Smith  advises  the  injection  into  the  tumor  of  a 
saturated  solution  of  monochloracetic  acid  by  means  of  a  specially 
constructed  syringe. 


Fig.  229. — Curtis's  adenoid  forceps. 

Adenoid  Growths. — These  hypertrophied  masses  of  lymphoid  tissue 
occur  with  great  frequency  in  the  vault  of  the  pharynx  and  give  rise 
to  catarrhal  symptoms,  deafness,  nasal  obstruction,  and  infection 
of  the  cervical  lymph  nodes.  If  neglected,  the  disease  produces 
a  marked  and  characteristic  deformity  of  the  face.  There  is  widening 
of  the  root  of  the  nose,  the  mouth  is  held  half-open,  the  incisor  teeth 
may  protrude,  and  the  child  gives  the  impression  of  being  stupid  or 
feeble-minded.  This  impression  is  accentuated  by  the  often  associated 
deafness. 

Treatment. — To  remove  these  growths,  the  child  should  always 
be  anesthetized.  The  mouth  should  be  held  open  by  a  mouth-gag, 
and  the  velum  drawn  forward  with  a  piece  of  tape  passed  through 
the  nares  and  out  of  the  mouth,  and  tied  over  the  lip.  The  operator 
should  stand  on  the  patient's  right,  and  with  the  forefinger  of  the  left 
hand  introduced  behind  the  palate  the  growth  should  be  located. 
A  pair  of  cutting  adenoid  forceps  (Fig.  229)  are  then  passed  along 
the  finger  to  the  vault  of  the  pharynx  and  the  growth  quickly  removed. 
After  the  chief  masses  are  removed,  the  remaining  fragments  may  be 


430 


INJURIES  AND  DISEASES  OF  FACE  AND  NECK 


scooped  out  by  the  Gottstein  curet  (Fig.  230).  These  cases  bleed 
freely  for  a  few  moments,  but  the  hemorrhage  is  easily  controlled 
by  an  injection  of  hydrogen  peroxide,  1  part  to  8  parts  of  water. 
Considerable  difficulty  often  is  experienced  in  removing  the  masses 
about  the  opening  of  the  Eustachian  tube,  and 
care  should  be  taken  to  avoid  wounding  this 
structure. 

Enlarged  Tonsils. — The  tonsils  are  not  infre- 
quently the  seat  of  a  pathologic  enlargement, 
which  may  produce  a  variety  of  symptoms.  It  is 
more  common  in  children,  as  most  lymphoid  tissue 
hypertrophies,  having  a  tendency  to  diminish 
with  advancing  age.  Thickness  of  speech,  diffi- 
culty in  swallowing,  mouth  breathing,  naso- 
pharyngeal catarrh,  and  a  tendency  to  acute 
infection  are  the  usual  symptoms.  There  is 
reason  to  believe  that  in  many  cases  of  tuber- 
culous infection  of  the  cervical  lymph  nodes, 
the  bacilli  gain  entrance  through  diseased  ton- 
sils and  adenoids,  and  recent  observations  have 
demonstrated  that  the  original  focus  of  infection 
in  cases  of  acute  and  chronic  arthritis,  may  be  located  in  chronically 
enlarged  tonsils. 

&  Treatment. — Formerly  surgeons  performed  tonsillotomy  by  means 
of  the  Mackenzie  (Fig.  231)  or  some  other  form  of  tonsillotome,  by 
which  only  a  part  of  the  gland  was  removed.  Frequent  recurrences 
led  later  to  a  more  thorough  removal  by  careful  dissection. 


Fig.  230. — Gottstein's 
curet. 


Fig.  231. — Mackenzie  tonsillotome. 


Recently  Mathews1  found  that  in  children  and  in  the  majority  of 
adults  the  entire  tonsil  could  be  enucleated  by  the  finger  (Fig.  232) 
if  the  mucous  membrane  at  the  summit  of  the  tonsil  between  the 


1  Annals  of  Surgery,  December,  1908. 


DISEASES  OF  THE  MOUTH,   PHARYNX,   AND  JAWS        431 

anterior  and  posterior  pillars  was  divided  and  the  normal  line  of 
cleavage  found. 

This  procedure  is  so  simple,  so  easily  performed,  and  so  thorough, 
that  it  is  to  be  recommended  in  preference  to  any  of  the  older  opera- 
tions. The  patient  should  be  anesthetized,  the  jaws  widely  separated 
and  held  by  a  mouth-gag.  The  tonsil  should  be  grasped  by  a  small 
vulsella,  drawn  outward,  and  the  mucous  membrane  at  its  upper 
border  divided  with  blunt  scissors.  The  point  of  the  closed  scissors 
is  next  pushed  through  the  cut  for  a  short  distance,  and  the  surrounding 
tissues  separated  by  partly  opening  the  blades,  after  which  the  tonsil 
is  easily  stripped  from  its  bed  by  the  finger.  After  this  enucleation, 
a  thin  strip  of  mucous  membrane  usually  remains  attached  to  its 
lower  pole,  which  is  divided  with  scissors  or  a  wire  snare. 

Papillomata,  sarcomata,  and  epitheliomata  occur  very  rarely  in  the 
nasal  fossa.  Tumors  of  the  antrum  will  be  considered  in  a  subse- 
quent section. 


Fig.  232. — Enucleated  tonsils. 


DISEASES  OF  THE  MOUTH,  PHARYNX,  AND  JAWS. 

Gangrenous  Stomatitis  (Noma). — Gangrenous  stomatitis  is  a  spread- 
ing gangrenous  ulcer  appearing  on  thejinside  of  the  cheek  or  lip,  of  a 
debilitated  person.  It  affects  young  children  chiefly,  and  especially 
those  who  live  amid  unhygienic  surroundings  and  who  are  recovering 
from  infectious  diseases  as  measles,  scarlatina,  and  typhoid  fever. 
Occasionally  it  is  encountered  in  adults  suffering  from  scurvy.  The 
disease  usually  starts  from  an  abrasion  of  the  mucous  membrane  due 
to  a  trauma,  or  from  a  roughened  tooth.  The  surrounding  area 
becomes  necrotic  and  secretes  a  foul  discharge,  which  often  is  swallowed 
by  the  patient.  The  process  spreads  rapidly,  and  unless  checked  by 
prompt  surgical  measures  results  in  extensive  destruction  of  tissue 
and  grave  septic  symptoms.  In  a  few  instances  the  gangrene  perforates 
the  cheek  and  may  involve  the  nose,  eyelids,  ear  and  even  the  bony 
structures.  There  is  usually  fever,  occasionally  with  chills,  sweats, 
and  a  rapid,  feeble  pulse.  In  other  cases  the  sepsis  may  be  of  the 
asthenic  type. 

Prognosis. — The  prognosis  is  exceedingly  grave. 

Treatment. — The  indications  for  treatment  are  to  remove  the 
necrotic  area  with  the  knife  or  actual  cautery  and  to  apply  powerful 
antiseptics,  as  pure  carbolic  acid,  hydrogen  peroxide,  or  formalin.    An 


432  INJURIES  AND   DISEASES  OF  FACE  AND  NECK 

abundance  of  good  food  and  judicious  stimulation  should  be  adminis- 
tered and  the  mouth  frequently  washed  with  antiseptic  washes. 

Glossitis. — Glossitis  is  an  inflammation  of  the  substance  of  the 
tongue.  It  is  caused  by  septic  stomatitis,  infected  wounds,  general 
toxic  conditions,  or  mercurial  poisoning. 

Symptoms. — The  symptoms  are  pain  and  swelling  in  the  organ  and  a 
limitation  of  its  movements.  The  surface  may  be  ulcerated  from 
pressure  on  the  teeth,  and  the  swelling  so  great  as  to  cause  the  tongue 
to  protrude  from  the  mouth  and  to  interfere  with  respiration.  The 
disease  in  some  instances  is  limited  to  one  side  of  the  tongue;  abscesses 
may  form  or  the  process  may  resolve.  A  particularly  malignant 
form  of  glossitis  has  been  described  by  Wright  and  others,  which 
causes  rapid  gangrene  of  the  organ  and  is  apparently  due  to  a  specific 
micro-organism. 

Treatment. — Apply  leeches  to  the  submaxillary  region,  ice  to  the 
tongue,  and,  if  necessary,  incise  over  the  area  of  greatest  induration. 

Chronic  Superficial  Glossitis. — Chronic  superficial  glossitis  is  a  dis- 
ease characterized  by  enlargement  of  the  papilla3  and  the  formation  of 
cracks  and  other  peculiar  markings  resembling  superficial  ulcerations. 
In  other  cases  there  is  an  overgrowth  of  epithelium,  giving  rise  to 
opaque  white  patches  (leukoplakia)  or  a  scaly  condition  (ichthyosis). 
These  conditions  may  or  may  not  be  associated  with  pain,  and  are 
important  on  account  of  the  fact  pointed  out  by  Butlin,  that  they  are 
very  liable  to  be  followed  by  cancer  of  the  organ. 

Tonsillitis. — Tonsillitis  is  of  interest  to  the  surgeon  for  the  reason 
that  it  is  the  immediate  cause  of  peritonsillar  abscesses,  and  often  is 
the  remote  cause  of  chronic  hypertrophy  of  the  tonsil  and  glandular 
enlargements  of  the  neck. 

Peritonsillar  Abscess. — Peritonsillar  abscess  is  a  cellulitis  of  the 
tissues  above  and  around  the  tonsil.  It  generally  follows  an  acute 
Streptococcus  tonsillitis,  and  is  characterized  by  edema,  induration, 
and  redness  of  the  palate  immediately  above  the  tonsil.  The  disease 
is  a  painful  one,  and  is  accompanied  often  by  fever,  chills,  and  severe 
toxemia.  On  examination  of  the  throat  with  the  finger,  a  distinct 
induration  generally  can  be  made  out,  and  is  the  guide  for  the  incision, 
which  constitutes  the  only  rational  method  of  treatment.  In  making 
the  incision  the  knife  should  penetrate  the  tissues  for  a  distance  of 
only  half  an  inch;  and  if  pus  is  not  reached,  a  grooved  director  or  stiff 
probe  should  be  introduced  into  the  wound  and  thrust  in  various 
directions  until  the  pocket  of  pus  is  reached.  Cocaine  may  be  used, 
although  it  is  rarely  of  much  service,  as  the  pain  is  due  more  to  the 
pressure  than  the  cutting.  If  general  anesthesia  is  employed,  the 
head  should  be  allowed  to  hang  backward  over  the  edge  of  the  table  to 
avoid  asphyxiation  from  the  flow  of  pus  into  the  larynx  and  trachea. 

Retropharyngeal  Abscess. — Retropharyngeal  abscess  is  a  collection 
of  pus  between  the  spinal  column  and  the  posterior  wall  of  the  pharynx. 
It  is  due  generally  to  suppuration  of  the  retropharyngeal  lymph  nodes 


DISEASES  OF  THE  MOUTH,   PHARYNX,   AM)  JAW'S         133 

from  infection  of  the  tonsils,  pharynx,  nose  or  accessory  sinuses; 
rarely  to  caries  of  the  vertebral  column  or  to  septic  osteomyelitis 
of  the  body  of  the  axis  or  arch  of  the  atlas. 

Treatment. — The  treatment  should  if  possible  be  by  external  incision 
behind  the  sternomastoid  muscle,  locating  the  abscess  by  a  probe  or 
director,  and  enlarging  the  opening  by  a  sinus-dilator  or  dressing- 
forceps.  Incision  through  the  pharyngeal  wall  may  be  necessary  if 
the  abscess  points  in  that  direction. 

Inflammation  of  the  Salivary  Glands. — Infection  is  carried  to  the 
salivary  glands  by  the  bloodvessels,  lymphatics,  or  by  the  ducts. 
In  the  epidemic  form,  mumps,  the  parotid  is  generally  affected,  although 
the  infection  may  occur  in  the  submaxillary,  sublingual,  or  as  once 
observed  by  the  author,  in  a  mass  of  aberrant  salivary  gland  tissue 
at  the  base  of  the  tongue.  In  the  ordinary  septic  or  metastatic 
type  of  the  disease,  which  occurs  most  frequently  in  the  parotid,  and 
which  is  observed  during  infectious  diseases  and  following  operations 
for  grave  septic  conditions,  the  glands  become  swollen,  hot,  and  tender; 
pain  is  present,  and  fever  may  develop.  The  process  ends  either  in 
resolution  or  suppuration.  The  treatment  of  suppuration  in  these 
glands  has  been  considered  under  the  headings  of  Abscess  of  the 
Parotid  and  Angina  Ludovici. 

Osteomyelitis  of  the  Jaws. — In  the  great  majority  of  instances 
osteomyelitis  of  the  jaws  is  caused  by  suppuration  around  the  root  of  a 
carious  tooth.  When  this  occurs  the  pus  may  loosen  the  tooth,  find 
its  way  along  the  wall  of  the  socket  and  infect  the  gum,  forming  a 
"gum-boil;"  or  it  may  infect  the  bone,  causing  an  osteomyelitis, 
which  may  be  limited  to  the  region  of  the  tooth  or  spread  throughout 
it-  entire  structure.  In  the  first  instance  it  causes  a  small  area  of 
necrosis,  through  which  the  pus  reaches  the  surface  and  collects  beneath 
the  periosteum,  forming  an  alveolar  abscess,  which  in  turn  may  infect 
the  surrounding  tissues  and  eventually  rupture  externally.  When 
the  inflammation  involves  a  large  portion  of  the  bone,  the  area  of 
necrosis  may  be  very  extensive,  subperiosteal  abscesses  form  and 
rupture,  and  the  periosteum  eventually  develops  an  involucrum,  in 
the  centre  of  which  the  necrosed  portion  of  bone  or  sequestrum  is 
imprisoned. 

Diagnosis. — The  diagnosis  of  simple  alveolar  abscess  is  readily 
made  by  observing  the  features  already  mentioned,  pain  and  tender- 
ness, and  a  limited  area  of  swelling  and  fluctuation.  In  the  more 
extensive  forms  generally  there  is  a  history  of  an  ulcerated  tooth, 
followed  by  swelling  of  the  cheek,  jaw,  or  submaxillary  region,  and  the 
formation  of  abscesses.  These  continue  to  discharge  in  spite  of  careful 
treatment,  and  there  gradually  develops  a  thickening  of  the  bone 
which  may  be  localized  or  general.  A  probe  introduced  into  one  of 
the  sinuses  will  generally  detect  bare  bone. 

Treatment. — Early  incision  down  to  the  bone  evacuating  the  sub- 
periosteal abscess,  often  will  abort  the  process.     In  many  instances, 
28 


434  INJURIES  AND  DISEASES  OF  FACE  AND  NECK 

however,  the  case  is  not  seen  by  the  surgeon  until  necrosis  has  taken 
place.  In  these  instances,  if  the  process  is  limited  in  extent,  free 
incision  through  the  mouth,  with  removal  of  dead  bone  by  a  sharp 
spoon  or  the  chisel,  and  subsequent  packing  of  the  cavity  with  iodoform 
gauze,  constitutes  the  best  treatment.  When  extensive  areas  of 
necrosis  are  present,  drainage  should  be  provided  by  free  incisions, 
which  if  possible  should  be  made  from  within  the  mouth.  At  a  later 
period,  when  the  involucrum  is  well  formed,  it  may  be  opened  and 
the  loose  sequestrum  removed.  Whenever  it  is  possible,  these  opera- 
tive procedures  should  be  carried  out  from  within  the  oral  cavity,  as 
the  scars  from  such  extensive  external  incisions  are  unsightly.  If, 
however,  a  number  of  sinuses  are  present,  it  may  be  necessary  to  attack 
the  disease  from  the  outside.  The  radical  operation  should  not  be 
undertaken  until  the  sequestrum  is  loosened  and  can  be  removed 
without  too  great  damage  to  the  involucrum.  The  usual  practice 
of  simply  opening  down  to  the  bone  and  scraping  it,  is  of  no  value 
whatever,  and  serves  only  to  increase  the  deformity.  At  best  the 
treatment  of  extensive  osteomyelitis  of  the  lower  jaw  is  unsatisfactory. 
When  the  process  attacks  the  upper  jaw,  the  results,  as  a  rule,  are 
better  for  the  reason  that  usually  less  extensive  areas  are  involved. 

TUMORS  OF  THE  MOUTH,  PHARYNX,  AND  JAWS. 

Cysts. — Cysts  of  the  floor  of  the  mouth  may  be  produced  by  obstruc- 
tion and  dilatation  of  the  ducts  of  the  mucous  glands  {ranida),  or 
more  rarely  by  dilatation  of  the  ducts  of  the  sublingual  gland.  They 
appear  just  beneath  the  mucous  membrane  of  the  floor  of  the  mouth 
on  either  side  of  the  frenum,  and  may  grow  to  the  size  of  a  hazel-nut 
or  robin's  egg.  Thev  are  semitranslucent  and  contain  a  clear  mucoid 
fluid. 

Treatment. — The  treatment  should  be  by  complete  excision  or  by 
removal  of  a  portion  of  the  cyst-wall  and  the  application  of  pure 
carbolic  acid  to  the  remaining  portion.  Cysts  occasionally  occur  just 
beneath  the  mucous  membrane  of  the  lateral  wall  of  the  pharynx,  and 
are,  as  a  rule,  of  branchial  origin.  Their  treatment  should  be  by 
excision,  preferably  from  without. 

Epithelioma. — Epithelioma  may  occur  as  a  primary  affection  in  the 
tongue,  floor  of  the  mouth,  the  cheeks,  the  gums,  the  palate,  or  in  the 
tonsil.  It  may  affect  the  jaws  secondarily.  As  a  rule,  the  disease 
appears  late  in  life,  and  in  the  first  four  situations  it  is  apt  to  follow 
severe  chronic  irritation  from  the  friction  of  a  ragged  tooth  or  the 
habitual  use  of  tobacco.  Great  enlargement  of  the  lymph  nodes  of 
the  neck  may  accompany  comparatively  small  epitheliomata  of  the 
mouth.  On  the  cheek  the  growth  is  apt  to  start  near  the  angle  of  the 
mouth ;  in  the  gums,  around  the  stump  of  a  decayed  tooth.  The  disease 
is  recognized  by  its  slow  growth,  its  indurated  borders,  its  steady 
progress,  and  by  involvement  of  the  lymphatics. 


TUMORS  OF   THE  MOUTH,   PHARYNX,   AND  JAWS         435 

Cancer  of  the  Tongue. — Cancer  of  the  tongue  is  by  far  the  most 
frequently  observed  type  of  malignant  disease  of  the  oral  cavity. 
It  occurs  commonly  in  men  past  middle  life.  It  may  arise  spon- 
taneously or  as  a  result  of  some  chronic  irritation.  In  not  a  few 
instances  it  is  apparently  engrafted  upon  a  gummatous  infiltration  of 
the  organ  or  upon  a  long-standing  leukoplakia. 

Symptoms. — Several  clinical  types  of  the  disease  are  to  be  recognized : 
first,  the  superficial  ulcer  which  occurs  on  the  lateral  margin  of  the 
tongue  often  opposite  a  carious  tooth;  second,  a  gradual  enlargement 
of  one  of  the  circumvallate  papillae;  third,  a  fissure  of  the  tip  or  dorsum ; 
fourth,  a  hard  nodule  in  the  mucous  membrane,  which  later  ulcerates 
and  resembles  the  first  variety.  All  of  these  lesions  are  superficial 
at  first,  but  later  infiltrate  the  muscles  and  cause  dense  induration. 
When  the  disease  is  engrafted  upon  a  leukoplakia  or  gumma,  it  is 
often  difficult  to  arrive  at  an  early  diagnosis,  and  valuable  time  is 
Jost  before  radical  treatment  is  inaugurated.  In  all  types  the  growth 
at  first  is  slow;  later  it  advances  more  rapidly,  and  is  accompanied  by 
pain,  difficulty  in  speech  or  deglutition,  and  eventual  enlargement  of 
the  submaxillary  lymph  nodes. 

Prognosis. — The  prognosis  in  cancer  of  the  tongue,  while  formerly 
regarded  as  extremely  unfavorable,  has  of  late  been  looked  upon  as 
more  encouraging,  owing  to  its  earlier  recognition  and  more  thorough 
methods  of  operation.  Mr.  Butlin,  of  London,  has  recently  published 
a  report  of  197  personal  operations  in  unselected  cases  with  an  operative 
mortality  of  a  trifle  less  than  11  per  cent.,  and  27  per  cent,  of  cures  after 
three  years.  In  70  cases,  where  he  removed  the  entire  contents  of  the 
submaxillary  triangle,  24  (or  42  per  cent.)  were  alive  at  the  end  of 
three  years.  In  cancer  in  other  parts  of  the  oral  cavity  the  prognosis 
is  less  favorable. 

Treatment. — The  treatment  should  be  early  and  complete  excision, 
with  removal  of  the  anatomically  related  lymph  nodes  and  the  lymph- 
bearing  areola  tissue  of  the  neck.  These  operations  will  be  described 
on  page  437. 

Sarcoma. — Sarcoma  may  occur  in  the  gums,  palate,  jaws,  tonsils,  and 
in  the  adenoid  tissue  at  the  base  of  the  tongue.  In  the  two  latter 
situations  the  disease  is  of  that  exceedingly  malignant  variety  called 
lymphosarcoma.  Several  forms  of  sarcoma  affect  the  tissues  of  the 
jaw,  the  least  malignant  of  which  is  the  giant-  and  mixed-cell  variety 
of  the  alveolar  border,  called  epulis.  Periosteal  sarcoma,  spindle- 
or  round-cell,  may  occur  on  any  part  of  the  superior  maxilla,  but  is 
more  common  on  its  anterior  surface  or  alveolar  process.  Both  the 
periosteal  and  the  central  variety  may  affect  the  mandible.  Slow- 
growing  localized  or  diffuse  hypertrophy  of  the  jaw  has  been  twice 
observed  by  the  writer  which,  upon  gross  inspection,  resembled  a 
normal  formation  of  new  bone,  but  which  strongly  suggested  chondro- 
sarcoma under  the  microscope.  Further  observation  made  it  probable 
that  the  disease  was  that  described  in  another  chapter  as  leontiasis. 


436  INJURIES  AND  DISEASES  OF  FACE  AND  NECK 

Sarcomata  originating  in  the  mucoperiosteum  of  the  antrum  are 
common,  and  their  growth  is  often  rapid,  bulging  the  walls  of  this 
cavity  and  encroaching  upon  the  nasal  chamber,  the  orbit,  the  spheno- 
maxillary space,  and  the  mouth. 

"Sarcoma  of  a  tooth-follicle  occurs  only  in  children,  and  is  particu- 
larly apt  to  involve  the  germ  of  the  first  permanent  molar"  (Bland- 
Sutton).  It  is  recognized  by  its  rapid  growth  and  the  other  character- 
istics of  sarcoma  already  mentioned.  The  treatment  is  early  and 
complete  removal. 

Adenoma. — An  encapsulated  adenomatous  tumor  occasionally 
occurs  in  the  tissues  of  the  soft  palate.  It  is  round  or  oval  in  shape, 
and  may  attain  the  size  of  a  hen's  egg.  It  is  not  malignant.  It 
should  be  removed  by  enucleation.  A  rare  and  exceedingly  rapid 
growing  tumor  of  the  palate,  resembling  the  above-mentioned  palatine 
adenoma,  may  occasionally  be  encountered,  which  is  extremely 
malignant.  It  also  occurs  in  the  region  of  the  gums,  probably  from 
aberrant  masses  of  salivary  gland  tissue.  It  is  classed  by  Volkmann 
among  the  endotheliomata. 

Osteomata,  papillomata,  angiomata,  lymphangiomata,  and  lipomata 
occasionally  occur  in  these  regions,  but  possess  no  special  features. 
Their  treatment  has  already  been  considered. 

Odontomata  and  Dental  Cysts. — These  tumors  are  often  loosely 
spoken  of  as  dentigerous  cysts.  They  may  occur  in  either  jaw,  and  are 
much  more  frequent  than  is  generally  supposed. 

Bland-Sutton  has  classified  these  tumors  as  follows:  An  epithelial 
odontome  is  a  tumor  growing  from  the  enamel-organ  of  the  tooth, 
and  made  up  of  small  cysts  containing  a  brownish  fluid.  It  is  encap- 
sulated and  may  distend  the  bone.  A  follicular  odontome  is  an 
expanded  tooth-follicle  containing  a  viscid  fluid  and  an  imperfectly 
developed  tooth.  A  fibrous  odontome  is  a  greatly  thickened  tooth-sac 
which  forms  a  dense  layer  of  fibrous  tissue  around  a  tooth,  preventing 
its  eruption.  A  compound  follicular  odontome  is  a  tumor  made  up  of 
cementum,  dentine,  and  often  a  large  number  of  imperfectly  developed 
teeth,  an  incomplete  ossification  of  the  tooth-capsule.  A  radicular 
odotome  grows  from  the  root  of  the  tooth,  and  is  made  up  of  dentine 
and  cementum,  but  no  enamel,  as  the  tumor  develops  after  formation 
of  the  crown  of  the  tooth,  which  does  not  undergo  change.  A  com- 
posite odontome  is  an  irregular  bony  tumor  occurring  in  the  jaw-bone 
or  in  the  antrum,  made  up  of  cementum,  enamel,  and  dentine.  It 
may  reach  a  large  size. 

These  tumors  are  often  regarded  as  osteomata,  osteosarcomata 
and  other  forms  of  new  growth.  The  true  diagnosis  is  rarely  made 
before  the  operation.  They  should  be  removed  with  a  chisel  and 
mallet  or  with  bone-forceps.  In  the  cystic  variety  it  is  often  only 
necessary  to  open  the  cavity,  curet,  and  pack. 

Gummatous  Infiltration. — Gummatous  infiltration  of  the  tongue, 
tonsil,  palate,  and  pharyngeal  wall  occurs  frequently,  and  must  be 


OPERATIONS  ON   TONGUE,   MOUTH,   PHARYNX,   AND  JAWS      131 

distinguished  from  new  growths.  It  occurs  first  as  a  rapidly  develop- 
ing tumor,  which  soon  breaks  down,  leaving  large  necrotic  ulcers  and 
often  resulting  in  extensive  losses  of  tissue.  In  the  tongue  the  process 
is  often  a  slow  one;  in  the  palate,  tonsil,  and  pharynx  it  is  frequently 
one  of  great  rapidity,  enormous  sloughs  occurring  in  a  few  days  follow- 
ing the  first  symptoms.  These  lesions  are  characterized  by  absence 
of  pain,  by  their  rapid  destruction  of  tissue,  and  by  their  prompt 
improvement  under  antisyphilitic  treatment. 

Tuberculous  Ulceration. — Tuberculous  ulceration  of  the  tongue  is 
rare,  and  generally  is  secondary  to  lung  tuberculosis.  It  occurs  on 
the  side  near  the  tip,  as  a  ragged,  undermined  ulcer  surrounded  by 
soft  tuberculous  nodules.  In  other  cases  it  is  simply  a  superficial 
erosion  surrounded  by  a  slightly  elevated  hard  border.  There  is,  as  a 
rule,  no  deep  or  massive  induration.  Tuberculous  ulcerations  in 
other  parts  of  the  oral  and  pharyngeal  cavities  are  extremely  rare. 
They  are  often  the  seat  of  spontaneous  pain,  differing  thereby  from 
the  syphilitic  lesions. 


OPERATIONS  ON  THE  TONGUE,  MOUTH,  PHARYNX,  AND  JAWS. 

Removal  of  the  Tongue. — Partial  or  complete  removal  of  the  tongue 
may  be  accomplished  through  the  mouth  ("Whitehead)  by  the  sub- 
maxillary operation  (Kocher)  or  by  one  of  the  several  methods  by 
which  access  to  the  region  is  gained  by  division  of  the  jaw. 

In  all  operations  for  malignant  disease  of  the  tongue  one  should 
strive  to  imitate  in  thoroughness  the  modern  operation  for  breast 
cancer.  Thus,  in  small  superficial  lateral  erosions  without  enlarged 
glands,  one-half  of  the  tongue  should  be  removed,  together  with  the 
submaxillary  gland,  all  the  areolar  tissue,  and  lymphatics  of  the 
submaxillary  triangle.  Where  the  disease  is  more  advanced,  with 
palpable  lymph  nodes,  the  entire  lymph-bearing  areola  tissue  of 
the  lateral  aspect  of  the  neck  should  be  removed,  as  well  as  the  sub- 
maxillary gland,  the  sternomastoid  muscle,  and  often  the  internal 
jugular  vein.  When  the  disease  approaches  or  passes  the  midline  of 
the  tongue,  the  entire  organ  should  be  removed.  Where  the  disease 
is  at  all  advanced,  that  portion  of  the  floor  of  the  mouth  containing 
the  infected  lymph  channels  should  be  thoroughly  removed  with  the 
submaxillary  tissues.  It  is  only  by  these  radical  procedures  so  strongly 
advocated  by  Crile  that  satisfactory  results  can  be  expected. 

Before  any  operation  on  the  tongue  the  patient  should  have  all 
carious  teeth  filled  or  removed;  and  for  several  days  prior  to  the 
operation  the  oral  cavity  should  be  frequently  disinfected  by  washes 
of  hydrogen  peroxide,  listerine,  or  boric  acid.  Ether  should  be  admin- 
istered by  means  of  Crile 's  nasal  tubes  and  the  pharynx  packed  with 
gauze;  or,  as  suggested  by  Butlin,  a  preliminary  thyrotomy  may  be 
employed  for  anesthesia.     If  the  Whitehead  procedure  is  followed, 


438  INJURIES  AND  DISEASES  OF  FACE  AND  NECK 

the  jaws  should  be  held  apart  by  a  mouth-gag;  the  tongue  should  next 
be  firmly  grasped  by  a  vulsellum  forceps  and  drawn  upward  and  out- 
ward. It  should  then  be  severed  from  its  connections  at  the  floor  of 
the  mouth  and  hyoid  bone  by  means  of  heavy,  blunt-pointed  scissors. 
The  lingual  arteries  should  be  clamped  as  they  are  cut,  and  subse- 
quently ligated  with  chromicized  catgut  or  silk.  If  the  Kocher 
method  is  employed,  an  incision  should  be  made  along  the  course  of 
the  digastric  muscle  from  the  symphysis  of  the  jaw  to  a  point  just 
below  the  lobule  of  the  ear,  dividing  the  skin,  superficial  fascia,  and  the 
platysma  muscle.  The  flap  is  dissected  from  the  deeper  parts  and 
drawn  upward  with  a  retractor.  The  deep  fascia  is  next  divided 
in  the  line  of  the  original  incision,  and  this  with  the  submaxillary  and 
sublingual  glands,  the  lymphatics,  and  the  areolar  tissue  of  the  part, 
thoroughly  removed.  The  lingual  artery  is  found  beneath  the  hyo- 
glossus  muscle  and  ligated.  If  the  entire  tongue  is  to  be  removed, 
the  lingual  artery  on  the  opposite  side  is  also  exposed  and  ligated.  The 
floor  of  the  mouth  is  then  divided  by  an  incision  along  the  ramus  of  the 
jaw,  and  the  tongue  drawn  downward  through  the  wound  by  means  of 
a  vulsellum  forceps  or  sharp  hook.  Partial  or  complete  excision  can 
then  be  performed  with  scissors.  After  removal  of  the  diseased  area 
the  mucous  membrane  of  the  floor  of  the  mouth  should  be  partly 
united,  the  external  wound  packed  or  partly  closed  with  sutures 
and  drained.  As  in  all  other  mouth  operations,  scrupulous  care 
should  be  taken  to  limit  the  local  infection  and  to  remove  its  products. 
The  patient  should  be  fed  by  the  rectum  for  one  or  two  days,  after 
which  food  should  be  administered  by  means  of  a  stomach-tube. 
The  cavity  of  the  mouth  should  be  washed  every  hour  at  least,  with 
weak  hydrogen  peroxide,  boric  acid,  or  myrrh  wash. 

Von  Langenbeck's  Operation  for  Removal  of  the  Tongue,  Tonsil, 
Floor  of  the  Mouth,  and  Palate. — An  incision  is  made  from  the  angle 
of  the  mouth  to  the  junction  of  the  anterior  margin  of  the  masseter 
muscle  with  the  lower  border  of  the  mandible,  and  from  this  point 
downward  and  forward  toward  the  great  cornu  of  the  hyoid  bone. 
The  lower  half  of  the  incision  is  carried  down  to  the  sheath  of  the  vessels 
and  the  external  carotid  ligated.  The  submaxillary  gland  and  the 
lymphatics  of  the  submaxillary  triangle  are  next  removed,  after  which 
the  upper  part  of  the  incision  is  carried  through  the  cheek  to  the  bone. 
A  Gigli  saw  is  then  passed  behind  the  ramus  of  the  jaw  through  the 
floor  of  the  mouth  and  the  bone  sawed  in  an  angular  fashion  to  prevent 
subsequent  displacement.  The  two  extremities  of  the  divided  bone 
are  then  retracted  by  sharp  hooks  and  the  diseased  tissues  readily 
removed  by  scissors  or  the  knife.  After  this  is  accomplished  the 
mucous  membrane  should  be  united  whenever  this  is  possible,  the  bone 
drilled  and  sutured  together  with  chromicized  catgut,  and  the  cutaneous 
wound  accurately  coapted  with  sutures  or  hare-lip  pins.  This  operation 
gives  the  best  exposure  of  the  parts,  but  is  open  to  the  objection  that 
the  bone  occasionally  fails  to  unite  and  necrosis  may  result. 


OPERATIONS  ON    TONGUE,   MOUTH,   PHARYNX,   AND  JAWS     439 

When  the  disease  is  situated  near  the  tip  or  is  bilateral,  division 
of  the  jaw  in  the  midline  (Sedilot's  operation)  is  to  be  recommended. 

Cheever's  Lateral  Pharyngotomy. — An  incision  is  made  along  the 
anterior  border  of  the  sternomastoid  muscle  from  the  lobule  of  the  ear 
to  a  point  opposite  the  cornu  of  the  thyroid  cartilage,  and  the  structures 
divided  down  to  the  deep  fascia,  which  is  opened.  The  external 
jugular  and  temporofacial  veins  are  divided  between  two  ligatures  and 
the  carotids  and  the  deep  jugular  retracted  outward.  The  digastric, 
stylohyoid,  and  stylopharyngeus  muscles  are  divided  or  retracted 
and  the  glossopharyngeal  and  hypoglossal  nerves  avoided.  The 
lateral  wall  of  the  pharynx  may  then  be  incised  on  a  sound  or  finger 
introduced  through  the  mouth,  and  any  growth  in  the  region  of  the 
tonsil  or  superior  laryngeal  aperture  removed.  After  careful  hemo- 
stasis  and  disinfection,  the  wound  in  the  pharynx  should  be  tightly 
closed  with  two  layers  of  fine  silk  and  the  superficial  structures  united, 
drainage  being  provided  for  at  the  lower  angle  of  the  wound. 

Removal  of  the  Upper  Jaw.  —  After  preliminary  ligation  of  the 
external  carotid  an  incision  should  be  made  along  the  lower  border  of 
the  orbit,  the  nasofacial  sulcus  around  the  ala  of  the  nose  to  the  median 
line,  and  from  there  downward  through  the  upper  lip  to  the  mouth. 
The  incision  should  be  carried  to  the  bone  and  the  flap  retracted 
outward,  exposing  the  entire  anterior  surface  of  the  superior  maxilla. 
The  central  upper  incisor  tooth  on  the  affected  side  should  then  be 
drawn  and  the  alveolar  process  and  hard  palate  divided  by  means  of  a 
saw  introduced  through  the  anterior  nares  or  by  a  heavy  bone-forceps. 
The  nasal  process  is  next  divided  by  the  forceps  and  the  zygoma  cut 
near  its  maxillary  extremity.  The  bone  should  then  be  grasped  by  a 
strong  pair  of  lion-jawed  forceps  and  wrenched  from  its  posterior 
attachments.  Considerable  bleeding  is  apt  to  follow  this  procedure, 
largely  from  the  pterygoid  plexus  of  veins,  which  must  be  controlled 
by  packing.  After  this  has  been  accomplished  the  parts  should  be 
thoroughly  inspected  for  evidences  of  disease,  which,  if  found,  can 
easily  be  removed  by  the  forceps  or  bone-curet.  The  skin  flap  should 
be  replaced  and  united  with  silkworm-gut  or  silk  sutures,  with  or 
without  one  or  more  hare-lip  pins  in  the  upper  lip. 

Removal  of  the  Lower  Jaw. — To  remove  one-half  of  the  lower  jaw, 
make  a  vertical  incision  through  the  lower  lip  to  the  symphysis  of  the 
chin,  then  along  the  inferior  border  of  the  horizontal  ramus  to  the 
angle,  then  upward  for  a  short  distance  toward  the  lobule  of  the  ear. 
The  soft  tissues  should  be  removed  from  the  bone  by  dividing  the 
mucous  membrane  along  the  alveolar  border  and  severing  the  muscular 
attachments  with  an  elevator.  The  symphysis  is  next  divided  by 
a  Gigli  saw.  The  tissues  forming  the  floor  of  the  mouth  should  then 
be  cut  close  to  the  bone  and  the  ascending  ramus  exposed  by  an 
incision  along  the  mucous  membrane  and  drawing  upward  of  the 
musculocutaneous  flap.  When  the  entire  half  of  the  bone  is  exposed 
the  horizontal  ramus  is  depressed  until  the  attachment  of  the  temporal 


440  INJURIES  AND  DISEASES  OF  FACE  AND  NECK 

muscle  can  be  seen  and  divided.  The  internal  pterygoid  muscle 
should  be  detached  from  the  inner  surface  by  an  elevator,  the  inferior 
dental  vessels  and  nerves  severed,  and  the  capsule  of  the  joint  exposed 
and  opened  from  in  front.  In  disarticulating,  care  should  be  taken 
to  avoid  wounding  the  internal  maxillary  artery,  which  lies  between 
the  neck  of  the  jaw  and  the  internal  lateral  ligament.  The  soft  parts 
should  then  be  replaced  and  united  with  hare-lip  pins,  silk  or  silkworm 
gut,  and  union  of  the  mucous  membrane  within  the  mouth  brought 
about  as  far  as  possible  by  stitching  with  catgut.  If  it  is  necessary 
to  remove  the  entire  mandible,  the  second  half  may  be  taken  out  in 
the  same  manner.  Partial  resection  of  the  lower  jaw  is  frequently 
necessary  for  osteomyelitis  or  epulis,  and  generally  can  be  effected 
through  the  mouth  without  external  incision. 

DISEASES  OF  THE  LARYNX,   TRACHEA,   AND  ESOPHAGUS. 

Injuries  of  the  Larynx,  Trachea,  and  Esophagus. — Injuries  of  the 
larynx,  trachea,  and  esophagus  have  been  considered  in  the  earlier 
part  of  the  chapter. 

Edema  of  the  Glottis. — Edema  of  the  glottis  is  a  swelling  of  the 
mucous  membrane  and  submucous  areolar  tissue  about  the  larynx 
and  vocal  cords,  giving  rise  to  dyspnea,  stridor,  loss  of  voice,  and  often 
complete  respiratory  obstruction  leading  to  sudden  death.  The  causes 
of  edema  of  the  glottis  are  acute  laryngitis  from  catarrhal  or  septic 
inflammation  of  the  neighboring  structures,  as  diphtheria,  peritonsillar 
abscess,  angina  Ludovici;  from  the  inhalation  of  live  steam,  irritating 
or  heated  vapors;  from  traumata,  tuberculous  or  syphilitic  ulcers, 
new  growths,  chronic  cardiac  or  renal  disease. 

Treatment. — The  treatment  of  this  condition  is,  in  the  milder  cases, 
by  applications  of  a  solution  of  cocaine  or  adrenalin  to  the  larynx, 
steam  inhalations,  and  the  internal  administration  of  cathartics 
and  aconite.  Whenever  the  symptoms  threaten  complete  obstruction 
or  are  progressive  in  character,  intubation  of  the  larynx  or  tracheotomy 
should  be  performed. 

Foreign  Bodies  in  the  Larynx  or  Trachea. — Particles  of  food  and 
other  solid  bodies  occasionally  are  aspirated  from  the  mouth  into  the 
air  passages.  The  accident  occurs  most  frequently  in  children  and  in 
vomiting  patients  during  or  after  the  administration  of  a  general 
anesthetic.  The  foreign  body  may  lodge  in  the  larynx,  trachea,  or 
one  of  the  bronchi. 

Foreign  bodies  in  the  larynx  give  rise  to  an  immediate  fit  of  violent 
coughing,  spasm  of  the  glottis,  cyanosis,  and  often  vomiting,  during 
which  the  foreign  body,  if  small,  may  be  expelled.  If  the  body  lodges 
in  the  trachea  the  symptoms  are  at  first  similar,  but  are  soon  relieved 
if  the  irritating  substance  becomes  fixed  below  the  larynx.  Coughing, 
however,  may  cause  a  renewal  of  the  dyspnea  and  spasm  by  again 
driving  the  intruder  upward  against  the  vocal  cords.     If  the  foreign 


DISEASES  OF  THE  LARYNX,   TRACHEA,   AND  ESOPHAGUS     441 

body  passes  into  one  of  the  bronchi  (generally  the  right),  more  or  less 
obstruction  may  develop  to  the  ingress  and  egress  of  air,  which  is 
apparent  by  auscultation;  and  if  the  obstruction  remains,  pneumonia, 
lung  abscess,  or  gangrene  may  result,  or  erosion  of  a  bloodvessel  and 
fatal  hemorrhage.  Exceptionally  a  foreign  body  may  remain  for 
years  in  the  lung  without  giving  rise  to  untoward  symptoms. 

Treatment. — Foreign  bodies  in  the  upper  part  of  the  larynx  fre- 
quently can  be  seen  by  the  laryngeal  mirror  and  removed  by  forceps. 
If  the  body  lies  below  the  vocal  cords,  give  ether  and  invert  the  patient, 
striking  the  back  violently  with  the  flat  of  the  hand.  This  may 
dislodge  the  body  and  it  may  be  expelled.  If  this  is  unsuccessful, 
perform  high  tracheotomy,  holding  the  edges  of  the  tracheal  wound 
wide  apart,  and  repeat  the  process  or  use  long,  thin-bladed  forceps. 
Foreign  bodies  in  the  lower  part  of  the  trachea  or  primary  bronchi 
occasionally  may  be  reached  by  forceps  through  a  low  tracheotomy 
wound.  If  the  body  is  lodged  in  one  of  the  smaller  bronchi,  the  prog- 
nosis is  exceedingly  grave.  During  the  past  few  years  the  method  of 
removing  foreign  bodies  from  the  trachea  and  bronchi  by  means  of 
Killian's  bronchoscope  has  steadily  grown  in  favor.  This  instrument 
is  simply  a  long  metal  tube  highly  polished  on  the  inside,  which  is 
carried  into  the  trachea  or  bronchi  through  the  mouth  or  through  a 
tracheal  wound.  A  strong  column  of  light  from  a  frontal  electric 
lamp  enables  the  operator  to  detect  the  presence  of  the  foreign  body, 
which  then  can  be  removed  by  specially  constructed  forceps  or  hooks. 
Considerable  technical  skill  is  required,  but  a  number  of  cases  are  on 
record  where  foreign  bodies  have  been  located  and  removed  from 
regions  as  remote  as  the  second  division  of  the  bronchial  tube  (Fig.  233). 

Foreign  Bodies  in  the  Esophagus. — Foreign  bodies  in  the  esophagus 
are  much  more  common,  as  coins,  marbles,  false  teeth,  and  many  other 
articles  frequently  are  swallowed  and  lodge  in  the  esophagus. 

Symptoms. — The  symptoms  of  a  foreign  body  in  the  esophagus  are 
localized  pain,  dysphagia,  and  salivation.  The  position  of  metallic 
bodies  can  be  located  by  the  metal  esophageal  bougie  or  the  .i*-rays. 
The  location  of  other  bodies  usually  can  be  determined  by  passing 
bougies  of  various  sizes  to  the  point  of  obstruction.  The  three  narrow- 
est parts  of  the  tube  are  at  its  commencement,  about  three  inches 
below  this  point,  and  at  the  esophageal  opening  in  the  diaphragm. 

Treatment. — Swallowing  quantities  of  soft  bread,  mush,  or  potato 
occasionally  will  carry  a  foreign  body  into  the  stomach.  Coins 
often  may  be  removed  by  the  coin-catcher  (Fig.  234);  other  substances 
by  the  esophageal  forceps  or  the  horse-hair  probang  (Fig.  235),  which 
should  be  introduced  closed  beyond  the  foreign  body,  opened,  and  with- 
drawn. If  these  measures  fail,  perform  external  esophagotomy 
and  attempt  removal  by  the  forceps.  This  is  usually  successful  for 
bodies  lodged  in  the  first  six  inches  of  the  tube.  When  the  foreign 
body  is  lodged  deep  in  the  thoracic  portion  of  the  esophagus  the 
esophagoscope  may  be  employed.     When  this  is  not  available,  have 


442 


INJURIES  AND   DISEASES  OF  FACE  AND  NECK 


the  patient  swallow  a  long  piece  of  silk  thread,  the  upper  end  of  which 
is  secured  bv  tying  to  the  ear  or  to  a  button  on  the  patient's  clothing. 


Fig.  233. — Upper  bronchoscopy.     Dorsal  position. 


THEKNV  rSCBEEREfi  CO.N.y, 

Fig.  234. — Coin-catcher. 


Fig.  235. — Horse-hair  probang. 


When  there  is  reason  to  believe  that  the  thread  has  passed  into  the 
stomach,  perforin  gastrostomy,  pick  up  the  thread  on  a  curved  probe 
introduced  into  the  stomach,  and  with  this  draw  downward  a  piece 


DISEASES  OF  THE  LARYNX,   TRACHEA,   AND  ESOPHAGUS     443 


of  heavy  braided  silk  or  bass  line,  in  centre  of  which  is  tied  a  mass  of 
gauze,  a  rubber  or  metal  cup.     This  contrivance  is  drawn  downward 

into  the  stomach  in  the  hope 
of  bringing  with  it  the  foreign 
body.  The  author  on  one  occa- 
sion wras  in  this  way  able  to  re- 
move a  detached  metal  bulb 
from  an  esophageal  bougie 
lodged  between  two  dense 
strictures  in  the  thoracic  por- 
tion of  the  esophagus.     (The 


Fig.  236. — Bulb  and  parachute  snare. 


Fig.  237. — Whalebone  sound   with 
adjustable  ivory  tips. 


bulb   and   the   "parachute  snare"  are  shown  in  Fig.  236.)     If  this 
fails,  resort  must  be  had  to  a  transthoracic  esophagotomy. 


444  INJURIES  AND  DISEASES  OF  FACE  AND  NECK 

Stricture  of  the  Esophagus.  Stricture  of  the  esophagus  is  generally 
due  to  swallowing  some  corrosive  substance,  as  lye  or  strong  acid,  to 
the  irritation  of  a  foreign  body,  to  the  healing  of  ulcers,  to  new  growths, 
to  the  pressure  of  an  aortic  aneurism,  or  to  hysteric  spasm.  When 
due  to  the  swallowing  of  a  corrosive  sustance  (the  commonest  cause), 
the  symptoms  are  at  first  those  of  an  acute  esophagitis:  pain,  dys- 
phagia, and  salivation.  Later  these  symptoms  disappear,  and  the 
patient  seems  well  and  free  from  discomfort  of  any  kind.  This  period 
of  calm  is  succeeded  by  a  gradually  increasing  difficulty  in  swallowing 
until  only  fluids  can  be  taken.  Wasting  rapidly  follows,  and  when 
fluids  are  no  longer  swallowed  emaciation  becomes  extreme. 

When  the  stricture  is  due  to  the  growth  of  a  tumor  or  the  pressure 
of  aneurism,  the  early  irritative  symptoms  are  wanting,  and  an  .r-ray 
plate  will  often  reveal  the  presence  of  a  tumor. 

Diagnosis. — The  diagnosis  of  stricture  of  the  esophagus  generally 
can  be  made  from  the  symptoms  just  mentioned,  but  it  is  desirable 
also  to  determine  the  location  of  the  point  of  narrowing,  and  the 
presence  or  absence  of  a  proximal  dilatation  of  the  tube.  The  former 
can  be  accurately  ascertained  by  use  of  the  esophageal  bougie,  the 
latter  by  an  .r-ray  plate  after  the  swallowing  of  bismuth  suspended 
in  gruel.  The  caliber  of  the  stricture  often  can  be  determined  by 
the  use  of  olive-pointed  bougies  of  various  sizes  (Fig.  237).  When  it 
is  impossible  to  pass  any  instrument  through  the  stricture,  owing  to 
the  presence  of  a  proximal  dilatation  or  sacculation  of  the  esophagus, 
or  because  of  a  tortuous  opening  through  the  strictured  area,  the 
examination  may  be  facilitated  by  the  use  of  Mixter's  tunnelled 
bougies  or  bulbous  sounds.  Five  or  six  feet  of  silk  thread  is  swallowed 
through  a  glass  feeding-tube  with  a  goblet  of  water.  This  usually 
passes  the  stricture,  enters  the  stomach  and  in  time  extends  well 
downward  into  the  small  intestine — allowing  considerable  tension 
to  be  made  upon  it  by  traction  upon  its  upper  end.  When  thus  drawn 
tense,  it  is  passed  through  the  eye  of  the  bougie  or  bulb,  and  the 
latter  guided  through  the  stricture.  In  this  way  the  number  of 
strictures  and  the  caliber  of  each  can  be  determined  in  the  majority 
of  instances. 

Treatment. — The  treatment  should  be  dilatation  by  means  of  flexible 
gum-elastic  esophageal  bougies  passed  every  second  day  until  one  40 
or  50  mm.  in  circumference  can  be  introduced,  after  which  the  instru- 
ment should  be  passed  by  the  patient  at  least  once  a  week. 

WThen  gradual  dilatation  is  impossible,  and  especially  in  those 
cases  in  which  starvation  is  rapidly  progressing,  gastrostomy  should  be 
performed  and  the  patient  generously  fed  through  the  fistulous  opening. 

When  strength  returns,  a  thread  should  be  swallowed,  and  by 
this,  a  piece  of  strong  braided  silk  or  fish-line  carried  through  the 
esophagus  from  the  mouth  downward  and  out  at  the  gastrostomy 
wound.  With  this  line  the  stricture  can  be  "sawed"  to  any  extent, 
care  being  taken  during  the  sawing  to  protect  the  mucous  membrane 


DISEASES  OF  THE  LARYNX,    TRACHEA,   AND  ESOPHAGUS      lb". 

of  the  stomach  and  throat  by  means  of  a  metal  tube  for  the  former  and 
a  perforated  tongue-spatula  for  the  latter.  The  presence  of  a  fusiform 
metal  bulb  attached  to  a  piece  of  piano-wire  (Fig.  238),  held  firmly 
against  the  stricture  during  the  cutting,  keeps  the  stricture  on  the 
stretch  and  prevent-  injury  to  other  parts  by  passing  through  the 
stricture  as  soon  as  it  is  sufficiently  enlarged.  When  all  strictures 
are  divided  in  this  way  to  Xo.  50  of  the  French  scale,  a  rubber  tube 
of  the  same  size  may  be  drawn  through  the  stricture  by  means  of  a 
piece  of  heavy  silk  or  twine  attached  to  either  end,  and  left  in  position 
for  several  days.  This  checks  hemorrhage,  and  if  the  tube  is  of  full 
size,  introduced  while  on  the  stretch  and  allowed  to  relax  after  it  is  in 
place,  a  certain  amount  of  continuous  dilatation  is  maintained.  If 
this  tube  is  employed.it  should  be  removed  at  the  end  of  twenty-four 
hours,  after  which  a  full-sized  bougie  or  bulb  should  be  passed  every 


Fig.  23S. — Metal  bulb  to  facilitate  the  sawing  of  esophageal  stricture. 

second  or  third  day  for  a  fortnight,  and  at  least  once  a  month  thereafter 
for  a  year.  When  a  proximal  dilatation  is  present  it  will  be  necessary 
to  employ  a  tunnelled  bougie  on  a  thread,  until  the  dilated  esophagus 
has  contracted  to  its  natural  size. 

Esophageal  Diverticula. — Esophageal  diverticula  may  be  congenital 
or  acquired.  The  acquired  variety  generally  are  due  to  stricture,  to 
traction  on  the  tube  by  neighboring  inflammatory  processes,  or  to 
hernia  of  the  mucous  membrane  through  an  abnormally  weakened 
muscular  coat  from  inside  pressure.  The  latter  variety  is  the  common- 
est and  usually  occurs  during  adult  life.  It  is  situated  at  or  near  the 
junction  of  the  pharynx  and  esophagus,  the  pouch  projecting  back- 
ward, and  subsequently  extending  downward  and  to  one  side. 

Symptoms. — The  symptoms  of  an  esophageal  diverticulum  are 
dysphagia,  the  frequent  regurgitation  of  large  amounts  of  mucus, 
and  the  presence  of  a  swelling  in  the  neck  during  the  process  of  swallow- 


446  INJURIES  AND  DISEASES  OF  FACE  AND   NECK 

ing  a  meal.  In  these  cases  the  patients  are  unable  to  swallow  solid 
pieces  of  food,  and  learn  to  subsist  chiefly  on  fluids  and  semisolids,  as 
mush,  custard,  and  scraped  beef  or  finely  hashed  meat.  The  first 
food  taken  at  a  meal  is  swallowed  with  difficulty  and  generally  passes 
into  the  diverticulum,  after  which  swallowing  is  easier,  the  food 
passing  over  the  filled  diverticulum  into  the  stomach.  An  esophageal 
bougie  passes  into  the  diverticulum  when  it  is  empty;  when,  however, 
it  is  filled  with  food,  the  bougie  often  may  be  introduced  into  the 
stomach.  The  diagnosis  can  be  easily  established  by  an  a--ray  plate 
after  swallowing  bismuth  gruel.  It  also  can  be  confirmed  by  the 
method  of  Plummer,  which  consists  in  passing  a  tunnelled  bougie 
on  a  previously  swallowed  thread.  If  the  thread  is  held  loosely  the 
bougie  passes  into  the  diverticulum,  and  is  arrested  when  it  reaches 
the  bottom  of  the  sac.  If  the  thread  is  then  drawn  taut  the  bougie 
rises  until  its  tip  is  on  a  level  with  the  opening  into  the  esophagus. 
It  can  then  be  easily  passed  along  the  tense  thread  guide  into  the 
stomach.  Careful  measurements  will  enable  the  surgeon  by  this 
method  to  estimate  the  depth  of  the  pouch. 

Treatment. — When  the  diverticulum  is  situated  in  the  neck,  it 
can  be  exposed  by  the  ordinary  incision  for  external  esophagotomy, 
the  pouch  removed,  the  esophageal  wound  sutured  with  two  or  more 
layers  of  fine  silk  or  chromicized  catgut,  and  the  external  wound 
closed  with  a  rubber  tissue  drain.  In  deep  thoracic  diverticula  little 
can  be  done  until  the  difficulty  in  swallowing  becomes  extreme.  In 
these  cases  gastrostomy  is  indicated. 

TUMORS  OF  THE  LARYNX. 

Both  benign  and  malignant  tumors  occur  in  the  larynx.  Of  the 
former,  papilloma  and  fibroma  are  the  most  common. 

Papillomata. — Papillomata  occurs  generally  before  middle  life,  and 
are  located  on  the  vocal  cords,  just  below  the  anterior  commissure, 
or  in  the  pyriform  sinus.  They  appear  as  pedunculated  or  sessile, 
wart-like  masses,  which  show  no  tendency  to  infiltrate  the  surrounding 
tissues.  In  adult  life  they  are  generally  single,  in  childhood  they 
are  often  multiple,  and  may  cover  the  ventricular  spaces,  vocal  cords, 
and  extend  into  the  trachea. 

Fibromata. — Fibromata  may  be  of  the  hard  or  soft  variety.  They 
are  most  frequently  encountered  on  the  vocal  cords  or  at  the  anterior 
commissure.  They  are  covered  by  intact  mucous  membrane,  and 
may  be  pedunculated. 

Epitheliomata. — Epithelioma^  occur  later  in  life  and  their  malig- 
nancy depends  largely  upon  their  location.  Those  situated  wholly 
within  the  larynx  I  intrinsic  cancer),  as  on  the  true  or  false  cords  in  the 
ventricles,  or  in  the  subglottic  space,  grow  slowly,  rarely  infect  the 
lymphatics,  and  almost  never  give  rise  to  visceral  metastasis.  Those 
occurring  at  the  superior  aperture  of  the  larynx  (extrinsic  cancer) 


TUMORS  OF  THE  LARYNX  447 

grow  more  rapidly,  infect  the  lymph  nodes  at  an  early  period,  are 
often  spread  to  the  tissues  of  the  pharynx  and  tongue.  In  more 
than  half  the  cases,  epithelioma  takes  its  origin  from  the  vocal  cord. 
It  first  appears  as  an  elevated  oval  nodule,  a  small  warty  growth, 
or  a  superficial  ulceration,  and  is  with  difficulty  differentiated  from  a 
fibroma,  benign  papilloma,  or  non-malignant  ulceration.  The  occur- 
rence, however,  of  a  peripheral  hyperemia  and  edema,  and  a  limitation 
in  the  mobility  of  the  cord  in  phonation,  is  strongly  suggestive  of  an 
infiltrating  growth. 

Symptoms. — Symptoms  of  tumor  of  the  larynx  are  a  progressively 
increasing  hoarseness,  cough,  and  dyspnea.  As  these  symptoms  are 
common  to  many  affections  of  this  organ,  the  diagnosis  can  only  be 
established  by  a  lar^ngoscopic  examination.  If  after  laryngoscopic 
examination  doubt  exists  as  to  the  nature  of  the  growth,  a  generous 
fragment  should  be  removed  with  forceps  and  subjected  to  microscopic 
examination. 

Prognosis. — The  prognosis  of  the  disease  varies  widely.  The  benign 
neoplasms,  as  a  rule,  grow  slowly,  and  if  located  on  a  part  of  the  mucous 
membrane  remote  from  the  vocal  cord  may  give  rise  to  no  symptoms. 
Tumors  arising  from  the  vocal  cord  or  at  a  point  just  above  or  below 
the  cord,  cause  hoarseness  at  all  times;  and  a  varying  degree  of  cough 
and  dyspnea,  depending  upon  the  amount  of  irritation  produced.  Often 
in  the  benign  cases  the  disease  seems  to  remain  stationary  for  months 
and  years.  In  epithelioma  on  the  other  hand,  there  is,  as  a  rule,  a 
progressive  increase  in  all  symptoms  as  the  tumor  advances.  In 
addition  to  the  hoarseness  and  cough,  pain  develops  and  later  signs 
of  stenosis,  with  redness,  edema,  and  tenderness  over  the  thyroid 
cartilage  indicating  the  presence  of  ulceration  or  necrosis.  At  this 
period  there  is  an  abundant  expectoration  of  a  foul,  bloody  or  puru- 
lent mucus,  which  may  by  inhalation  give  rise  to  a  terminal  septic 
pneumonia. 

Treatment. — Small  papillomata  of  the  larynx  often  may  be  made 
to  disappear  by  inhalations  of  a  spray  of  alcohol  (Delavan)  or  by 
the  application  of  caustic  agents.  The  best  method  of  treatment, 
however,  is  by  removal  with  cutting  forceps  under  guidance  of  the  eye 
by  means  of  a  laryngoscope.  This,  however,  should  only  be  under- 
taken by  a  skilled  laryngologist.  Subglottic  tumors  are  reached  and 
easily  removed  by  median  thyrotomy.  Intrinsic  cancer  of  the  larynx 
in  its  earliest  stages  often  may  be  successfully  removed  by  thyrotomy 
(Butlin)  or  by  partial  laryngectomy.  Total  laryngectomy  is,  however, 
the  operation  of  choice  in  all  cases  of  malignant  disease  of  the  organ 
in  which  the  growth  involves  the  opposite  side  of  the  larynx,  the 
commissure,  or  where  there  is  evidence  that  the  cartilage  is  eroded. 
In  advanced  cases  it  should  always  be  accompanied  by  extensive  bloc 
dissection  of  the  lymphatics  and  the  lymph-bearing  areolar  tissue  of 
the  neck.  This  method  should  also  be  adopted  in  malignant  growths 
of  the  superior  aperture  of  the  larynx,  as  in  these  cases  the  disease 


44S  INJURIES  AND  DISEASES  OF  FACE  AND  NECK 

quickly  involves  the  lymphatics  and  pursues  a  much  more  rapid 
course.  In  advanced  inoperable  cases,  radium  or  the  .r-rays  may  be 
employed,  and  where  dyspnea  from  stenosis  exists,  tracheotomy 
is  indicated. 

Tuberculous  and  Syphilitic  Ulcerations. — Tuberculous  and  syphilitic 
ulcerations  of  the  larynx  are  of  frequent  occurrence.  The  former 
begin  in  the  arytenoids  or  vocal  cords,  and  gradually  extend  to  the 
other  tissues,  including  the  pharynx.  The  latter  begin  by  a  gummatous 
infiltration  of  the  epiglottis  or  cords,  which  soon  breaks  down,  forming 
typical  syphilitic  ulcers  which  extend  to  the  neighboring  tissues. 
Perichondritis  and  necrosis  of  the  cartilages  may  occur.  Obstinate 
cicatricial  stenosis  frequently  follows  syphilitic  ulceration.  The  treat- 
ment is  purely  medical  until  stenosis  occurs. 

TUMORS  OF  THE  TRACHEA. 

New  growths  of  the  trachea  are  rare.  Of  the  benign  growths 
papillomata  and  fibromata  are  the  most  common.  Lipomata ,  chondro- 
mata,  and  adenomata  have  been  observed.  Intratrachial  struma 
or  aberrant  masses  of  thyroid  tissue  also  occur  in  the  trachea,  chiefly 
on  the  posterior  wall. 

Of  the  malignant  growths,  carcinoma  and  sarcoma  are  to  be  con- 
sidered. The  former  occurs  with  greater  frequency,  the  proportion 
being  two  to  one. 

Symptoms. — Tracheal  tumors  rarely  give  rise  to  symptoms  until 
stenosis  occurs.  Dyspnea  is  generally  the  first  symptom.  Later 
there  is  cough  with  increased  dyspnea  and  cyanosis  on  exertion. 
Papillomata  not  infrequently  develop  just  above  the  tracheal  opening 
in  patients  after  tracheotomy,  and  who  for  any  reason  are  obliged  to 
retain  the  tube  for  a  long  period  of  time.  The  treatment  is  by  an 
extensive  tracheotomy  or  laryngotracheotomy  with  removal  of  the 
growth  if  benign.  In  malignant  cases  more  or  less  extensive  tracheal 
resections  may  be  necessary. 

TUMORS  OF  THE  PHARYNX  AND  ESOPHAGUS. 

Epithelioma. — Epithelioma  occurs  in  the  pharynx  near  the  base  of 
the  tongue  and  in  the  upper  part  of  the  esophagus. 

Cancer. — Cancer  of  the  thoracic  portion  of  the  esophagus  is  apt  to 
be  of  the  glandular  variety,  and  affects  chiefly  the  lower  portion  of  the 
tube  as  it  passes  through  the  diaphragm. 

Diagnosis  and  Treatment  of  Tumors  of  the  Pharynx  and  Esophagus.— 
Tumors  of  the  lower  pharynx  and  esophagus  rarely  give  rise  to  symp- 
toms until  they  extend  to  other  organs,  as  the  larynx,  or  cause  obstruc- 
tion. The  first  symptom  is  generally  dysphagia,  which  gradually 
increases  until  typical  symptoms  of  stricture  are  produced.  The 
extension  of  a  pharyngeal  growth  to  the  larynx  is  indicated  by  dyspnea 


PLATE  XV 


Ulcerating  Secondary  Carcinoma  of  Lymph   Nodes  of  Neck. 

Probably  arising   from    some    unrecognized   foeus    in    pharynx  or  esophagus, 
or  possibly  from  a  small  branchial  epithelioma.     (Lumiere  photograph.) 


OPERATIONS  ON  LARYNX,   PHARYNX,  AND  ESOPHAGUS     449 

and  loss  of  voice.  Pain  occurs  as  a  later  symptom.  Benign  tumors 
when  accessible  sometimes  can  be  removed  by  lateral  or  infrahyoid 
pharyngotomy  or  by  external  esophagotomy.  The  treatment  of 
malignant  tumors  of  the  esophagus  has  until  quite  recently  been 
unsatisfactory.  At  a  recent  meeting  of  the  International  Congress  of 
Surgery,  Gluck,  of  Berlin,  exhibited  a  number  of  cases  of  advanced 
malignant  disease  of  the  larynx,  pharynx,  and  esophagus  successfully 
operated  upon  by  thorough  local  removal  and  extensive  bloc  dissec- 
tions of  the  lymphatics  of  the  neck.  Carcinoma  of  the  thoracic  portion 
of  the  esophagus  may  be  approached  by  a  transthoracic  operation, 
by  the  use  of  a  negative  pressure  cabinet  or  better,  by  positive 
pressure  anesthesia  by  the  intratracheal  method.  Torek  has  recently 
reported  a  successful  case. 

Sarcomata  may  occur  in  the  pharynx,  very  rarely  in  the  larynx 
or  trachea,  except  by  extension  from  other  regions. 

Angiomata,  lipomata,  and  myomata  have  been  observed. 


OPERATIONS    ON    THE  LARYNX,    PHARYNX,   AND  ESOPHAGUS. 

Thyrotomy. — This  operation  is  undertaken  for  the  prompt  relief 
of  sudden  edema  of  the  glottis  or  other  forms  of  respiratory  obstruction 
occurring  at  the  rima  glottidis.  In  an  emergency  it  may  be  performed 
by  plunging  the  blade  of  a  pocket  knife  through  the  lower  part  of 
the  thyroid  cartilage  and  cricothyroid  membrane,  and  separating 
the  edges  of  the  wound  by  turning  the  blade  sidewise  or  inserting 
the  handle  of  the  knife,  a  key,  or  bent  hairpin.  Performed  in  this 
manner  there  is  always  danger  of  hemorrhage  from  a  branch  of  the 
cricothyroid  artery. 

Complete  Section  of  the  Thyroid  Cartilage. — Complete  section  of 
the  thyroid  cartilage  in  the  median  line  is  employed  for  examination 
of  the  interior  of  the  larynx  and  for  the  removal  of  intralaryngeal 
growths.  The  patient  should  be  placed  in  the  Trendelenburg  posture 
and  a  preliminary  tracheotomy  performed,  with  closure  of  the  trachea 
by  means  of  a  sponge  inserted  above  the  canula  or  by  the  use  of  a 
Hahn  tube.  An  incision  should  then  be  made  in  the  median  line  from 
the  hyoid  bone  to  the  second  or  third  ring  of  the  trachea,  dividing 
all  structures  down  to  the  cartilage.  The  larynx  should  then  be 
opened,  the  two  halves  separated,  and  the  parts  inspected.  After 
carrying  out  the  necessary  intralaryngeal  procedures  the  cartilages 
may  be  brought  accurately  together  and  held  by  several  sutures,  or 
the  wound  packed  with  sterile  gauze.  The  tracheal  tube  should  be 
retained  until  the  danger  from  edema  or  hemorrhage  has  passed. 

Tracheotomy. — In   the   majority   of    instances   in   adult   patients, 

local  anesthesia  should  be  employed  for  this  operation.     In  children, 

especially    where    marked    dyspnea    is    present,    general    anesthesia, 

preferably  chloroform,  should  be  used.     An  incision  should  be  made 

29 


450 


INJURIES  AND  DISEASES  OF  FACE  AND  NECK 


in  the  median  line  over  the  trachea,  the  sternohyoid  and  sternothyroid 
muscles  drawn  outward  by  retractors,  and  the  trachea  exposed  above  or 
below  the  isthmus  of  the  thyroid.  Several  large  veins  are  often  encoun- 
tered both  above  and  below  the  deep  fascia,  which  should  be  secured 
and  divided  between  ligatures.  When  the  trachea  is  bared,  clearly 
exposing  the  rings,  and  when  all  hemorrhage  is  arrested,  a  vertical 
incision  should  be  made  into  the  tube,  the  edges  of  the  wound  separated 


Fig.  2.'jU. — Tracheal  dilator. 

by  a  tracheal  dilator  (Fig.  239),  and  a  tracheal  tube  (Fig.  240)  intro- 
duced and  held  securely  in  place  by  a  tape  passed  around  the  neck. 
One  or  two  cutaneous  sutures  may  be  inserted  or  the  wound  packed 
with  gauze.  Following  the  tracheotomy,  patients  whould  be  kept  in  a 
warm  room  and  the  head  of  the  bed  surrounded  by  a  tent  of  blankets 
to  avoid  draughts  of  air  (Fig.  243).  A  croup  kettle  or  steam  atomizer 
is  of  advantage  in  some  cases  to  render  the  inspired  air  moist  and 
warm.     The  patient  should  be  carefully  watched,  the  tube  regularly 


Fig.  240. — Tracheal  tube. 


cleaned,  the  wound  frequently  dressed,  and  the  inspired  air  at  first 
filtered  by  passing  through  several  layers  of  loose  gauze.  There  is  a 
fairly  high  mortality  following  tracheotomy,  from  the  frequent  occur- 
rence of  septic  pneumonia.  This  always  should  be  considered  in 
performing  the  operation  preliminary  to  other  operations  on  the  upper 
air  passages.     The  pneumonia  in  these  cases  is  largely  due  to  the 


OPERATIONS  ON  LARYNX,   PHARYNX,   AND  ESOPHAGUS      451 

inhalation  of  blood  during  the  operation  and  of  septic  material  after 
recovery  from  the  anesthetic.  Great  care  should,  therefore,  be  used 
to  avoid  both  of  these  dangers. 

Intubation  of  the  Larynx. — This  operation  consists  in  the  introduc- 
tion into  the  larynx  of  a  metal  or  gutta-percha  tube  so  constructed 


Fig.  241. — Tracheotomy  tube  in  position. 

as  to  fit  its  lumen,  and  provided  with  a  flange  on  its  upper  extremity 
to  rest  upon  the  false  cords.  The  operation  is  performed  by  a  special 
set  of  instruments  devised  by  O'Dwyer  (Fig.  244).  No  anesthetic 
is  required  in  ordinary  cases.  The  patient  sits  or  is  held  in  front  of  the 
operator  with  the  mouth  widely  open.     The  surgeon  then  adjusts 


Fig.  242. — Konig's  spiral  canula. 

the  tube  to  the  introducer,  passes  his  left  forefinger  over  the  base 
of  the  tongue  to  the  epiglottis,  which,  with  the  base  of  the  tongue, 
is  drawn  well  forward.  The  tube  is  next  passed  into  the  pharynx 
and  the  tip  directed  into  the  laryngeal  entrance  by  elevating  the 
handle  of  the  introducer.     As  soon  as  the  tube  passes  the  glottis, 


452 


INJURIES  AND  DISEASES  OF  FACE  AND  NECK 


it  is  pushed  from  the  introducer  by  means  of  a  lever  device  on  the 
handle  and  the  tube  pressed  well  downward  by  the  forefinger  of  the 
left  hand.  In  removing  the  tube,  the  orifice  is  located  with  the  finger, 
the  tip  of  the  extractor  passed  into  its  lumen,  the  jaws  opened,  and 
both  tube  and  extractor  removed. 

Laryngectomy. — The  operation  is  performed  in  two  stages.  Under 
local  anesthesia  a  median  incision  is  made  extending  from  the  cricoid 
to  the  sternal  notch.  The  muscles  are  separated,  exposing  the  isthmus 
of  the  thyroid,  which  is  doubly  ligated  and  divided.  The  separated 
edges  are  pushed  to  each  side  and  the  trachea  freely  exposed.     A 


Fig.  243. — Tracheotomy  tent  showing  patient  after  total  laryngectomy. 


low  tracheotomy  is  then  performed  and  the  canula  introduced,  after 
which  the  upper  part  of  the  incision  is  united  with  silkworm-gut 
sutures,  and  the  peritracheal  space  generously  packed  with  iodoform 
gauze  both  above  and  below  the  canula  (Fig.  245).  The  wound  is 
dressed  and  the  patient  placed  under  a  tracheotomy  tent  (Fig.  243), 
into  which  a  small  amount  of  steam  is  introduced  by  means  of  a  croup 
kettle.  The  external  opening  of  the  tracheal  canula  is  constantly 
covered  with  four  or  five  layers  of  gauze  which  may  be  dampened  with 
boric  acid  solution  with  a  view  to  filtering  the  air  which  enters  the 
trachea.     A  special  day  and  night  nurse  attends  the  patient. 


OPERATIONS  ON  LARYNX,   PHARYNX,    AND  ESOPHAGUS      l.j.'! 

About  ten  days  after  the  preliminary  operation,  if  the  patient  has 
a  normal  temperature  and  is  not  suffering  from  cough  or  excessive 
tracheal  secretion,  the  secondary  operation  is  undertaken.  Chloro- 
form is  administered  through  the  tube  until  the  patient  is  anesthetized, 
after  which  its  administration  is  continued  in  the  same  manner,  or 
colonic  etherization  is  employed  by  means  of  the  Sutton  apparatus. 

The  use  of  scopolamine  (gr.  T^¥)  and  of  morphine  (gr.  |)  one-half 
hour  before  operation  is  a  decided  advantage  in  these  cases,  as  it 
not  only  diminishes  to  a  considerable  extent  the  amount  of  anesthetic 
required,  but  in  addition  it  minimizes  tracheal  secretion,  lessens  the 


m|   t^^Wtk"  Hi 

I 

mmlQ 

j 

4 :  ■  ;■'■; 

^•••^»»g  M    i 

Fig.  244. — O'Dwyer's  intubation  instruments:  A,  tube  with  obturator;  B,  tube; 
C,  obturator;  D,  metal  gauge;  E,  mouth-gag;  F,  introducer;  G,  extractor;  H,  silk 
cord.     (Fowler.) 

postoperative  vomiting,  and  insures  a  period  of  from  one  to  four  hours 
of  freedom  from  restlessness  after  the  operation,  a  time  when  most 
laryngeal  cases  are  coughing,  and  increasing  thereby  the  always- 
present  tracheal  irritation.  Recently  the  author  was  able  to  perform 
a  total  laryngectomy  under  local  novocaine  anesthesia,  except  for  a 
few  minutes,  while  the  esophagus  wound  was  being  sutured,  when 
chloroform  was  employed.  This  procedure  is  to  be  advised  in  an 
intelligent  patient  with  a  high  degree  of  self-control. 

The  patient  is  placed  on  a  flat  table  with  the  head  well  extended. 
An  incision  is  made  from  the  body  of  the  hyoid  downward  to  the 


451 


INJURIES  AND  DISEASES  OF  FACE  AND  NECK 


upper  limit  of  the  former  cut.  From  the  upper  extremity  of  this 
incision  two  lateral  incisions  are  made  in  an  upward  and  outward 
direction,  extending  to  the  anterior  borders  of  the  stemomastoid 
muscles.  The  two  triangular  flaps  are  turned  outward,  the  sternohyoid 
muscles  divided  just  below  their  attachment,  and  the  sternothyroids 
detached  from  the  cartilage.  The  two  superior  thyroid  arteries  are 
next  located  and  ligated.  The  superior  laryngeal  nerves  are  cut  and 
all  lymph  nodes  and  neighboring  lymph-bearing  areolar  tissues  are 
removed.  The  attachments  of  the  inferior  constrictors  are  next 
divided  and  the  posterior  surface  of  the  cricoid  partly  separated  from 
the  esophagus  by  blunt  dissection. 


Fig.  245. — Preliminary  tracheotomy  with  gauze  packing  about  trachea. 


When  the  larynx  is  thoroughly  skeletonized,  the  trachea  is  severed 
just  below  the  cricoid,  and  its  distal  extremity  immediately  packed 
tightly  with  gauze,  completely  preventing  the  entrance  of  blood  or 
pharyngeal  mucus.  The  forefinger  of  the  left  hand  is  next  introduced 
into  the  upper  or  laryngeal  segment  of  the  tube  and  the  larynx  gently 
raised  from  the  esophagus,  any  remaining  attachments  being  separated 
by  gauze  sponges  (Fig.  246).  When  the  larynx  is  thus  completely 
separated  from  the  esophagus,  the  tips  of  the  thyroid  cornua  are 
divided,  the  thyrohyoid  membrane  incised,  and  the  larynx  removed. 
The  pharyngeal  wound  is  then  packed  with  gauze  to  prevent  excessive 


OPERATIONS  ON  LARYNX,    PHARYNX,   AND  ESOPHAGUS     455 

contamination  of  the  wound,  and  the  parts  carefully  inspected  for 
evidences  of  remaining  disease.  The  oval  pharyngeal  wound  is  next 
tightly  closed  by  two  layers  of  suture,  the  first  of  plain  catgut,  the 
second  of  chromic  catgut.  After  closure  of  the  pharyngeal  opening, 
the  entire  upper  wound  is  temporarily  packed  with  wet  formalin 
gauze,  while  the  tracheal  stump  is  prepared  for  closure.  This  is 
accomplished  by  dissecting  out  or  destroying  with  cautery  the  mucous 
membrane  above  the  opening  for  the  canula,  and  tightly  closing  the 


Fig.  246. — Section  of  trachea  with  packing  of  distal  extremity. 


superior  orifice  by  two  mattress  sutures  of  heavy  chromic  catgut. 
A  No.  30  F  rubber  feeding  tube  is  then  introduced  through  the  nostril 
into  the  esophagus  and  secured  by  a  safety  pin  and  plaster  straps  to 
the  face.  The  wounds  are  next  united  above,  with  generous  gauze 
packing  about  the  tracheal  canula  (Fig.  247).  Water  is  given  through 
the  tube  as  early  as  the  morning  following  the  operation  if  there  is  no 
nausea.  Milk,  coffee,  egg-nog,  meat  juice,  and  soups  follow  as  soon 
as  possible.  No  attempt  at  swallowing  should  be  made  for  at  least 
seven  days,  after  which  the  tube  can  be  removed.     The  wound  should 


456 


INJURIES  AND  DISEASES  OF  FACE  AND  NECK 


be  dressed  at  least  once  every  day,  and  two  or  three  times  if  there  is 
infection  or  pharyngeal  leakage. 

The  tracheal  stump  is  quickly  covered  with  granulations  and 
gives  no  trouble.  The  patients  continue  with  the  silver  canula. 
The  after-treatment  should  be  the  same  as  that  following  tracheotomy. 
Patients  should  be  encouraged  to  assume  a  sitting  posture  as  soon  as 
possible  after  operation.  In  the  earliest  stage  of  intrinsic  cancer  of 
the  larynx,  extensive  dissection  of  the  neck  is  not  necessary,  as  the 
lymphatics  are  rarely  involved.  At  a  later  period,  however,  and  in  all 
cases  of  extrinsic  growth,  a  thorough  removal  of  all  nodes  and  lymph- 
bearing  areolar  tissue  is  imperative. 


Fig.  247. — Wound  sutured,  showing  packing  about  trachea. 

Subhyoid  Pharyngotomy. — Subhyoid  pharyngotomy  is  occasionally 

useful  for  the  removal  of  a  small  growth  in  the  upper  larynx.  After 
a  preliminary  tracheotomy,  transverse  incision  should  be  made  just 
below  the  hyoid  bone  and  the  thyrohyoid  membrane  exposed.  When 
all  bleeding  is  arrested,  this  should  be  incised,  the  epiglottis  drawn 
outward  or  excised,  and  the  necessary  procedures  carried  out,  after 
which  the  wound  should  be  closed  with  subcutaneous  drainage. 

External  Esophagotomy. — An  incision  is  made  along  the  anterior 
border  of  the  left  sternomastoid  muscle  from  a  point  opposite  the 
upper  margin  of  the  thyroid  cartilage  to  the  sternoclavicular  articula- 
tion, dividing  the  skin,  superficial  fascia,  and  platysma.     The  omohyoid 


DISEASES  OF  THE  EAR  457 

muscle  is  retracted  and  the  tissues  separated  by  blunt  dissection  until 
the  great  vessels  are  reached.  These  are  carefully  retracted  outward, 
the  thyroid  "land  and  overlying  muscles  retracted  inward,  and  the 
lateral  wall  of  the  trachea  and  esophagus  exposed.  The  recurrent 
laryngeal  nerve  should  he  found  in  the  groove  between  these  two 
structures  and  held  aside.  An  esophageal  bougie  is  next  introduced 
from  the  mouth  and  the  esophagus  opened  upon  it  as  a  guide.  After 
the  necessary  procedures  have  been  carried  out,  the  esophageal  wound 
should  he  closed  with  two  layers  of  fine  silk  or  chromicized  catgut  and 
the  superficial  structures  united  by  layer  suture.  A  rubber  tissue 
or  cigarette  drain  should  be  introduced  whenever  the  wound  has  been 
contaminated. 

DISEASES  OF  THE  EAR. 

Deformities. — The  external  ear  may  be  notched,  the  pinna  may  lie 
absent,  or  the  entire  ear  may  project  abnormally,  giving  rise  to  an 
unsightly  appearance.  These  deformities  may  be  corrected  by 
plastic  operations. 

Furuncles. — Furuncles  occur  with  great  frequency  in  the  external 
auditory  canal,  and  cause  much  annoyance  by  the  pain,  tenderness,  and 
swelling  of  the  parts.  They  occur  usually  in  crops;  as  many  as  ten 
or  twelve  ma}'  appear  in  an  individual  in  as  many  weeks.  They 
should  be  promptly  incised  and  the  ear  frequently  irrigated  with 
carbolic  acid  solution  (1  to  100).  As  in  cases  of  furunculosis  elsewhere, 
an  effort  should  be  made  to  increase  the  resistance  of  the  individual 
by  tonics,  fresh  air,  exercise,  and  raising  the  opsonic  index  by  the 
hypodermic  injection  of  autogenous  vaccines. 

Hematoma. — Hematoma  of  the  external  ear  occurs  in  the  insane 
and  as  a  result  of  trauma.  The  lesion  is  a  subperichondrial  hemorrhage 
which  frequently  causes  great  thickening  of  the  tissues  and  a  deformity 
which  never  fully  disappears.  As  a  rule,  no  treatment  is  required. 
Occasionally  when  the  bleeding  occurs  on  the  posterior  aspect  of  the 
cartilage,  incision  and  removal  of  the  clots  may  be  indicated  if  the  case 
is  seen  sufficiently  early. 

Otitis  Media. — Otitis  media  is  an  acute  inflammation  of  the  mucous 
membrane  lining  the  cavity  of  the  tympanum,  usually  caused  by  an 
ascending  infection  through  the  Eustachian  tube. 

Symptoms. — The  symptoms  are  pain  in  the  ear,  deafness,  fever,  and 
a  rapid,  full  pulse.  The  pain  is  severe  and  often  of  a  lancinating 
character.  On  examination,  the  drum-membrane  will  be  found 
reddened  and  bulged  outward.  This  disease  is  of  interest  to  the 
surgeon  chiefly  on  account  of  its  complications.  If  untreated,  acute 
otitis  media  may  be  spontaneously  relieved  by  rupture  of  the  drum- 
membrane  and  evacuation  of  the  pus.  If  considerable  pressure 
exists  from  an  accumulation  of  pus  or  septic  fluid,  the  infection  may 
spread  to  the  mastoid  antrum,  giving  rise  to  pain  and  tenderness  behind 


458  INJURIES  AND  DISEASES  OF  FACE  AND  NECK 

the  ear,  with  redness  and  edema  of  the  skin  and  subcutaneous  tissues. 
If  this  condition  is  not  promptly  relieved  by  operation,  the  infection 
may  extend  to  the  neighboring  mastoid  cells,  causing  a  more  or  less 
extensive  osteomyelitis,  which  not  infrequently  involves  the  lateral 
sinus,  causing  septic  thrombosis,  pyemia,  and  death;  or  to  the  meninges 
or  brain,  giving  rise  to  septic  meningitis,  cerebritis,  or  brain  abscess. 
These  latter  complications  are  often  the  result  of  an  acute  exacerbation 
of  an  old  subacute  otitis  media,  the  only  symptom  of  which  may  be  the 
presence  of  chronic  otorrhea. 

Treatment. — The  treatment  of  acute  otitis  media  should  be  prompt 
incision  of  the  drum  and  the  relief  of  tension.  The  incision  should  be 
made  in  the  lower  posterior  quadrant  of  the  membrane,  and  should 
be  followed  by  frequent  irrigations  with  a  warm  solution  of  boric 
acid.  Early  incision,  during  the  first  few  hours  of  the  pain,  when 
the  cavity  is  filled  simply  with  clear  serum  often  will  abort  the  process. 
The  relief  to  the  pain  is  immediate  and  the  opening  in  the  drum  heals 
perfectly  in  a  few  days. 

Mastoiditis. — Although  in  general,  cases  of  otitis  media  and  mastoidi- 
tis are  best  referred  to  the  specialist,  the  general  surgeon  not  infre- 
quently is  called  upon  for  their  treatment  in  acute  septic  conditions. 
Mastoid  suppuration  is  practically  always  a  sequel  of  otitis  media 
and  is  characterized  by  pain  and  tenderness  behind  the  ear  extending 
often  to  the  tip  of  the  process.  If  the  infection  is  acute,  there  will  be 
redness  and  edema  over  the  affected  area  with  fever  and  leukocytosis. 

Treatment. — The  treatment  of  mastoiditis  should  be  prompt  to 
avoid  extension  of  the  disease  to  the  brain  or  lateral  sinus.  An  incision 
should  be  made  behind  the  ear  from  a  point  three-quarters  of  an 
inch  above  the  meatus  downward  to  the  tip  of  the  process.  The 
incision  is  carried  to  the  bone  and  the  periosteum  and  soft  parts 
retracted.  An  opening  is  then  made  by  a  small  chisel  or  gouge  into 
the  mastoid  antrum,  which  lies  in  the  swprameatal  triangle,  a  space 
bounded  by  the  upper  posterior  margin  of  the  bony  canal,  and  two 
lines  drawn  tangent  to  the  roof  and  posterior  wall  of  the  bony  meatus. 
The  antrum  lies  about  three-fifths  of  an  inch  below  the  surface.  In 
the  early  cases  all  that  will  be  required  is  a  free  opening  into  the  antrum, 
with  disinfection  and  packing  with  gauze.  If  the  disease  has  spread 
to  the  other  cells  of  the  mastoid  process,  it  may  be  necessaty  to  expose 
and  open  them  down  to  the  tip  of  the  process. 

The  treatment  of  sinus  thrombosis  and  of  the  cerebral  complications 
of  the  disease  has  been  considered  in  Chapter  XIII. 


CHAPTER  XVIII. 

INJURIES  AND  DISEASES  OF  THE  THORAX,  PLEURA, 

AND  LUNG. 

INJURIES  OF  THE  CHEST-WALL. 

Contusions. —  Contusions  of  the  chest-wall  are  of  frequent  occur- 
rence, and  are  only  important  on  account  of  the  complicating  visceral 
injuries  which  may  be  associated  with  them. 

In  the  majority  of  instances  severe  contusions  of  the  chest  are 
accompanied  by  fracture  of  one  or  more  ribs,  the  diagnosis  and  treat- 
ment of  which  will  be  considered  in  Chapter  XXVII . 

Rupture  of  the  parietal  or  visceral  layer  of  the  pleura,  injury  of 
the  lung,  and  injuries  of  the  pericardium  and  heart,  may  occur  from 
severe  blows  or  contusions  of  the  chest  without  fracture  or  external 
wounds.  Fatal  shock  has  also  been  observed  without  apparent  visceral 
injury. 

Injuries  of  the  pleura  are  indicated  by  pain  which  is  increased 
by  deep  inspiration,  and  by  the  presence  of  a  friction-sound  over 
the  seat  of  injury.  Rupture  of  the  lung  is  indicated  by  cough,  bloody 
expectoration,  and  the  evidences  of  hemothorax  and  pneumothorax. 
Exceptionally  no  signs  of  visceral  injury  are  apparent  at  the  first 
examination.  Subpleural  injury  of  the  lung  may  occur,  and,  in 
addition  to  the  cough  and  bloody  expectoration,  may  cause  a  subpleural 
emphysema  which  travels  upward  to  the  root  of  the  lung  through  the 
mediastinal  areolar  tissue  to  the  root  of  the  neck,  and  from  there  may 
spread  in  any  direction.  In  these  cases  pressure  on  the  heart  and 
great  vessels  frequently  leads  to  disturbed  heart  action,  marked 
dyspnea,  congestion  of  the  face,  and  dilatation  of  the  superficial  veins 
of  the  neck.  The  diaphragm  is  occasionally  ruptured  by  a  severe 
contusion  or  crush  of  the  chest-wall,  and,  in  some  instances,  a  hernia 
of  the  stomach  or  other  of  the  abdominal  viscera  may  take  place  into 
the  pleural  cavity.  Blows  over  the  lower  left  chest  often  produce 
alarming  symptoms  of  shock,  which  sometimes  is  fatal. 

Treatment. — The  treatment  of  uncomplicated  contusions  of  the 
chest  calls  for  nothing  other  than  rest  and  limiting  the  respiratory 
movements.  This  is  accomplished  best  by  a  firm  binder  or  adhesive 
plaster  strips.  If  rupture  of  the  lung  is  present,  strapping  the  chest 
will  limit  the  respiratory  movements  and  give  relief  if  the  hemorrhage 
is  not  progressive.  Absolute  rest  should  be  enjoined,  and,  if  the 
symptoms  of  progressive  hemorrhage  are  present,  threatening  life, 


460      DISEASES  OF  THORAX,  PLEURA,  AND  LUNG 

the  chest  should  be  opened  and  an  effort  made  to  find  and  secure  the 
bleeding  point.  It  not  infrequently  happens  that  a  thoracotomy 
which  allows  air  to  enter  the  pleural  cavity  will  cause  the  arrest  of 
hemorrhage  by  collapse  of  the  lung. 

Wounds  of  the  Chest-wall. — Wounds  of  the  chest-wall  may  be  pene- 
trating or  non-penetrating.  The  former  are  generally  caused  by 
severe  compound  fractures  or  by  gunshot  or  stab  wounds.  If  the 
wound  is  of  sufficient  size  to  admit  air  to  the  pleural  cavity,  pneumo- 
thorax results,  which  is  indicated  by  cough,  dyspnea,  rapid  respiration, 
the  absence  of  respiratory  sounds  over  the  affected  side,  and  the 
presence  of  an  abnormal  tympanitic  resonance.  Wounds  in  the  lower 
half  of  the  chest  are  not  infrequently  complicated  by  wounds  of  the 
diaphragm,  and  if  sufficiently  large  a  hernial  protrusion  into  the 
thorax  of  the  stomach  or  intestine  may  occur.  In  rare  instances  the 
injury  may  involve  the  thoracic  duct,  giving  rise  to  chylothorax. 

In  stab  wounds  of  the  chest  with  hemorrhage  from  a  vessel  of 
the  chest-wall,  the  blood  is  often  aspirated  into  the  pleural  cavity 
by  the  respiratory  efforts,  little  or  none  escaping  at  the  surface  of  the 
wound. 

In  gunshot  wounds  of  the  thorax,  those  made  by  the  modern  small- 
caliber  high-velocity  weapons  produce,  as  a  rule,  much  less  damage 
than  those  made  b}  the  older  large-caliber  arms.  In  the  former 
the  track  of  the  projectile  is  more  often  sterile,  there  is  less  splintering 
of  bone,  less  laceration  of  lung  tissue,  and,  consequently,  less  hemor- 
rhage and  sepsis.  Other  things  being  equal  perforating  gunshot 
wounds  of  the  chest  are  less  serious  than  simple  penetrating  wounds, 
where  the  bullet  remains  in  the  pleural  cavity  or  is  imbedded  in  the 
lung.  Injuries  occurring  near  the  root  of  the  lung  are  more  dangerous 
than  those  situated  at  a  distance  from  the  large  vessels.  It  was 
observed  in  the  Spanish-American  and  South  African  wars  that 
many  perforating  wounds  of  the  thorax  made  by  Mauser  bullets  and 
other  small-caliber,  high-velocity  projectiles,  healed  kindly  and  often 
without  symptoms,  the  only  dressing  being  the  application  of  a  sterile 
pad  over  the  external  wounds. 

If  the  lung  is  wounded,  cough  will  be  present  and  will  be  accompanied 
by  bloody  expectoration.  If  bleeding  occurs  into  the  pleural  sac, 
either  from  a  wound  in  the  lung  or  from  an  injured  vessel  in  the  chest- 
wall,  hemothorax  will  be  produced,  indicated  by  the  presence  of  flatness 
over  the  lower  part  of  the  chest  with  absence  of  fremitus  and  of  the 
normal  respiratory  sounds.  If  the  bleeding  is  considerable,  it  may  fill 
the  greater  part  of  the  pleural  sac  and  give  rise  to  all  the  signs  and 
symptoms  of  concealed  hemorrhage.  Subcutaneous  emphysema  is  a 
frequent  symptom  of  wounds  of  the  chest.  Non-penetrating  wounds 
of  the  chest-wall  present  no  special  features. 

Lenormant  has  recently  expressed  the  opinion  that  in  these  cases 
of  extensive  hemothorax,  death  more  often  results  from  pressure  on  the 
heart  and  mediastinal  structures,  than  from  the  actual  loss  of  blood. 


INJURIES  OF  THE  CHEST-WALL  461 

Treatment. — In  regard  to  the  treatment  of  penetrating  wounds  of 
the  thorax,  surgical  opinion  is  divided.  Many  surgeons  of  large 
experience  as  Zeidler  and  Lavroff,  advise  operation  in  all  cases,  for  the 
reason  that  the  extent  of  the  injury  cannot  be  determined  by  the 
early  symptoms  and  signs.  Other  authorities,  of  equal  experience, 
including  Lucas-Championniere,  Lenormant  and  Holmberg,  advise 
conservative  treatment  in  the  absence  of  symptoms  and  signs  of 
alarming  or  progressive  hemorrhage,  greatly  embarrassed  respiration, 
gross  septic  contamination  of  the  pleura,  or  a  probability  of  injury  to 
the  heart,  mediastinal  structures  or  diaphragm.  In  the  treatment 
of  these  injuries  it  must  be  remembered  that  there  is  a  strong  prob- 
ability of  cardiac  injury  if  the  wound  occurs  in  the  "heart  zone" 
described  by  Zeidler,*  as  the  space  limited  above  by  the  second  rib, 
externally  by  a  line  from  the  junction  of  this  rib  with  the  anterior 
axillary  line  to  the  seventh  intercostal  space  on  the  nipple  line.  Also 
that  all  penetrating  wounds  below  the  fourth  intercostal  space  may 
injure  the  diaphragm. 

In  injuries  of  the  diaphragm,  thoracotomy  is  necessary,  and  the 
wound  should  be  repaired  by  drawing  the  edges  together  with 
chromic  catgut  sutures.  In  injuries  of  the  esophagus  a  larger 
thoracotomy  wound  will  be  necessary,  with  ample  retraction  of  the 
collapsed  lung,  to  insure  accurate  suture.  In  all  of  these  operations, 
positive  pressure  anesthesia  by  the  intratracheal  method  of  Meltzer 
and  Auer  should  be  employed:  skilled  assistants  and  a  good  light 
are  essential;  the  question  of  drainage  must  be  determined  by  the 
probable  amount  of  contamination  of  the  pleura.  Where  there  is 
reason  to  believe  that  the  pleural  cavity  has  not  been  grossly 
infected,  and  there  are  no  signs  of  alarming  hemorrhage,  or  of  injury 
to  the  heart  or  diaphragm,  the  external  wound  should  be  carefully 
disinfected  and  sealed  with  a  sterile  dressing.  Embarrassed  respira- 
tion occurring  later  as  a  result  of  pneumothorax  or  the  presence  of 
blood  or  a  serous  exudate,  often  may  be  relieved  by  aspiration.  If 
empyema  develops,  drainage  should  be  established. 

Probing  the  wound  is  dangerous,  and,  as  a  rule,  furnishes  no  valuable 
information.  Air  in  the  pleural  cavity  is  quickly  absorbed  if  the  wound 
of  entrance  is  sealed.  Free  blood  in  the  pleural  cavity  quickly  clots, 
and  if  sterile  absorbs  readily.  The  presence  of  blood  and  air  from  an 
external  wound  in  the  pleural  cavity  usually  results  in  infection  and 
empyema.  Blood  in  the  pleural  cavity  with  air  from  a  wound  in  the 
lung  without  external  contamination  generally  remains  sterile,  and 
eventually  is  absorbed.  If  there  is  reason  to  believe  that  a  penetrating 
wound  of  the  chest  is  infected,  it  should  be  explored,  enlarged  if 
necessary,  and  the  pleural  cavity  drained  with  gauze  or  rubber 
tube. 

In  the  presence  of  a  progressively  increasing  hemothorax,  the 
wound  into  the  pleural  cavity  should  be  enlarged  by  the  removal 
of   one  or  more  rib  segments,  the  clots  removed,  the  sources  of  the 


462 


DISEASES  OF   THORAX,   PLEURA,   AND  LUNG 


hemorrhage  located  and  treated  if  possible  by  ligation  or  the 
suture-ligature.  If  this  is  impossible,  gauze  packing  may  be  em- 
ployed with  pressure  at  or  near  the  bleeding  point. 


DISEASES  OF  THE  CHEST-WALL. 

Abscess. — Abscesses  of  the  chest-wall  differ  in  no  way  from  abscesses 
in  other  parts  of  the  body,  excepting  those  which  occur  under  the 
pectoral  muscle  and  those  which  occur  in  the  axilla. 


Fig.  248. — Chronic  suppurative  pleurisy;  chronic  osteomyelitis  of  the  ribs. 

Subpectoral  Abscess.- — Subpectoral  abscess  results  from  a  cellulitis 
beneath  the  pectoral  muscles,  which  may  arise  from  a  neighboring 
wound,  from  lymphatic  infection,  from  disease  of  the  bone,  or  as  a 
part  of  some  general  septic  disease.  The  symptoms  may  be  misleading 
at  first,  but  localized  pain  is  generally  present,  and  is  greatly  increased 
on  attempting  to  raise  the  arm  above  the  head.  Fluctuation  is  often 
obscured  by  the  overlying  muscle.  The  treatment  should  be  by  free 
incisions  and  drainage. 


PLATE  XVI 


Tuberculosis  01  Costal  Cartilages. 
(Lumiere  Photograph.) 


TUMORS  OF  THE  CHEST-WALL  463 

Axillary  Abscess. — Axillary  abscess  is  generally  the  result  of  infection 
of  the  axillary  lymph  nodes.  The  suppuration  may  be  extensive 
and  burrow  deeply  in  the  axilla  around  the  great  vessels  and  nerve- 
trunks.  The  treatment  should  consist  in  freely  opening  the  axilla, 
with  removal  of  the  pus  and  diseased  glands.  This  can  only  be 
accomplished  by  a  generous  incision,  a  good  light,  and  ample  retraction 
of  the  wound  edges.  The  knife  should  be  sparingly  used,  and  after 
the  first  incision  is  made  removal  of  the  diseased  glands  may  be  accom- 
plished largely  by  the  finger  or  blunt  dissection. 

Osteomyelitis  of  the  Ribs. — Osteomyelitis  of  the  ribs  or  sternum 
may  occur  and  give  rise  to  abscesses  with  more  or  less  extensive 
necrosis  of  the  bones.  Acute  septic  osteomyelitis  is  rarer  than  the 
typhoid,  syphilitic,  or  tuberculous  variety.  It  is  apt  to  occur  in  the 
rib  near  the  chondral  junction.  The  process  at  first  involves  the 
medullary  cavity,  finally  erodes  the  cortex,  and  produces  a  subperiosteal 
abscess,  which  in  turn  may  rupture  on  the  surface  or,  rarely,  within 
the  pleura.  In  typhoid  osteomyelitis  the  process  is  subacute,  as  a 
rule,  and  the  bone  focus  much  more  limited  in  extent.  In  the  tuber- 
culous variety  the  entire  course  of  the  disease  may  be  painless,  the 
first  indication  being  the  presence  of  an  oblong,  fluctuating  swelling- 
over  the  rib  without  heat  or  redness. 

In  the  acute  septic  variety  there  is,  as  a  rule,  severe  boring  pain, 
with  edema  and  redness  of  the  overlying  soft  parts,  fever,  and  evidences 
of  toxemia. 

Treatment. — In  the  treatment  of  the  septic  variety  of  osteomyelitis 
of  the  ribs  or  sternum  early  incision  through,  the  periosteum  will 
often  give  marked  relief  and  limit,  to  a  considerable  extent,  the  destruc- 
tion of  bone.  In  all,  thorough  removal  of  the  bone  focus  is  essential, 
followed  in  the  tuberculous  cases  by  curetting  and  packing  with 
iodoform  or  formalin  gauze. 

TUMORS  OF  THE  CHEST-WALL. 

Tumors  of  the  chest-wall  are  conveniently  divided  into  those 
arising  from  the  soft  parts  and  those  taking  their  origin  from  the 
bony  framework.  Of  the  former  may  be  mentioned  fibroma  and 
fibroma  molluscum,  lipoma,  sarcoma;  sebaceous,  dermoid,  or  echino- 
coccus  cysts;  of  the  latter,  osteoma,  chondroma,  and  sarcoma  are  the 
most  important. 

The  tumors  of  the  soft  parts  differ  in  no  respect  from  similar  tumors 
developing  in  other  parts  of  the  body  which  have  already  been 
sufficiently  considered. 

Osteomata  are  most  frequently  found  growing  from  the  ribs  at 
or  near  their  junction  with  the  costal  cartilages.  In  the  majority 
of  instances  they  represent  ossified  chondromata.  They  give  rise  to 
no  symptoms,  and  are  of  surgical  interest  only  when  the  deformity 
renders  removal  necessary. 


464  DISEASES  OF   THORAX,   PLEURA,  AND  LUNG 

Chondromata  are  found  less  frequently  in  the  sternum  than  in  the 
ribs,  and  in  either  situation  are  generally  near  a  joint.  They  so 
frequently  degenerate  into  sarcoma  that  Quenu  and  Longuet  advise 
the  same  radical  removal  as  for  sarcoma. 

Sarcoma  is,  undoubtedly,  the  most  frequently  observed  tumor 
of  the  bony  thorax.  It  occurs  as  a  central  or  periosteal  pure  growth 
or  as  a  mixed  tumor  (osteo-  chondro-  or  myxosarcoma).  A  rare 
and  exceedingly  soft  pulsating  endothelioma  of  bone  is  occasionally 
observed  in  this  locality. 

Prognosis. — The  prognosis  in  sarcoma  of  the  thoracic  wall  is  exceed- 
ingly grave,  as  only  the  most  thorough  removal  at  an  early  date  will 
give  hope  of  a  radical  cure. 

Treatment. — In  chondroma  of  the  ribs  or  sternum  wide  excision 
is  to  be  advised  in  the  early  stage.  In  sarcoma  and  in  recurrent 
or  advanced  chondroma  of  the  ribs,  complete  resection  of  the  chest- 
wall  is  the  operation  of  choice,  for  the  reason  that  the  involvement 
of  the  pleura  takes  place  at  an  early  period.  In  sarcoma  of  the  sternum 
extensive  operation  is  demanded,  but  is  a  formidable  procedure  on 
account  of  the  danger  of  wounding  important  mediastinal  structures. 


DISEASES  OF  THE  PLEURA. 

Pneumothorax. — This  is  a  condition  characterized  by  the  presence 
of  air  in  the  pleural  cavity. 

It  may  arise  from  an  external  wound,  from  traumatic  rupture  of 
the  lung,  from  rupture  of  a  tuberculous  cavity,  or,  rarely,  from  infection 
by  a  gas-producing  micro-organism.  The  effect  of  a  pneumothorax 
unassociated  with  an  external  wound  (closed  pneumothorax)  is  only  a 
moderate  interference  with  respiration  noticed  on  unusual  exertion. 

Where  there  is  an  open  pleural  wound  (open  pneumothorax)  the 
dyspnea  is  more  marked,  due  not  only  to  collapse  of  the  affected 
lung,  but  to  the  absence  of  the  piston  action  of  the  diaphragm.  Len- 
ormant  has  recently  described  a  particularly  dangerous  type  of  pneu- 
mothorax which  he  designates  pneumothorax  a  soupape,  or  valvular 
pneumothorax;  in  which  by  the  condition  of  the  external  wound,  air 
is  aspirated  into  the  pleura  by  each  inspiratory  act,  but  none  escapes. 
This  quickly  results  in  great  intrapleural  pressure,  dislocation  of  the 
heart  and  other  mediastinal  structures,  giving  rise  to  grave  and 
increasing  dyspnea. 

Symptoms. — The  symptoms  of  open  pneumothorax  are  dyspnea 
and  cyanosis  on  exertion,  cough,  rapid  heart  action,  and  extreme 
discomfort.  If  the  opposite  lung  is  diseased,  all  of  these  symptoms 
are  exaggerated.     Double  pneumothorax  is  generally  fatal. 

Treatment. — In  spontaneous  pneumothorax  from  the  rupture  of 
a  tuberculous  cavity  no  operative  treatment  is  required,  as  the  gradual 
collapse  of  the  lung,  from  the  accumulated  air  and  the  associated 


DISEASES  OF  THE  PLEURA  465 

serous  effusion,  favors  closure  of  the  pulmonary  opening.  At  a  later 
period  the  fluid  gradually  may  be  removed  by  aspiration. 

Jn  open  pneumothorax,  if  uninfected,  closure  of  the  thoracic  wound 
generally  gives  prompt  relief  by  restoring  the  piston  action  of  the 
diaphragm.  In  pneumothorax  a  soupape  aspiration  should  be  tried, 
and  if  the  symptoms  recur,  the  valvular  opening  should  be  enlarged, 
a  drainage  tube  inserted,  and  later  one  of  the  methods  of  aspiration 
drainage  employed.  If  the  pleura  is  infected,  drainage  must  be 
instituted. 

Removal  of  the  air  by  aspiration  from  a  closed  pneumothorax 
with  disease  of  the  other  lung,  will  often  give  a  large  measure  of 
relief. 

Hydrothorax. — Hydrothorax  is  an  effusion  of  serum  into  the  pleural 
sac.  This  affection  is  caused  by  pleuritis  or  pneumonia,  by  wounds 
of  the  pleura  or  lung,  by  foreign  bodies,  new  growths,  or  by  tuberculo- 
sis. It  occurs  also  as  a  bilateral  affection  in  chronic  renal  or  cardiac 
disease  and  in  general  sepsis. 

Symptoms. — The  symptoms  are  a  gradually  increasing  shortness 
of  breath  on  exertion  and  cough.  The  signs  are  a  diminished  area 
of  resonance  and  respiratory  murmur,  flatness,  absence  of  fremitus, 
and  egophony. 

Treatment. — The  treatment  should  consist  in  the  administration 
of  cathartics  and  diuretics.  Removal  of  the  fluid  by  aspiration  is 
to  be  recommended  if  absorption  is  slow  or  fails  to  occur. 

Chylothorax. — The  presence  of  chyle  in  the  pleural  cavity  is  due  to 
rupture  of  the  thoracic  duct,  generally  the  result  of  a  fracture  of  the 
spine  or  crush  of  the  chest.  The  diagnosis  is  made  by  an  exploring 
needle. 

Repeated  aspirations  have  in  some  cases  resulted  in  a  cure  of  the 
condition. 

Pyothorax  (Empyema). — Pyothorax  or  empyema,  is  a  collection  of 
pus  in  the  pleural  sac.  This  occurs  as  a  result  of  infection  of  a  pre- 
existing pleuritic  effusion,  or  may  arise  immediately  as  a  result  of  a 
penetrating  wound  of  the  thorax,  from  extension  from  a  neighboring 
septic  focus  as  a  pneumonia,  an  abscess  of  the  lung,  chest-wall,  liver, 
or  subphrenic  region.  It  may  arise  also  from  lymphatic  extension 
from  an  abdominal  focus.  In  certain  cases  the  process  is  distinctly 
localized  and  is  shut  off  from  the  general  pleural  cavity  by  adhesions. 
In  other  rare  instances  such  a  collection  of  pus  may  be  situated  between 
the  lobes.  This  variety  cannot  be  differentiated  from  abscess  in  the 
lung-tissue.  In  the  great  majority  of  cases  empyema  follows  pneu- 
monia. When  due  to  the  pneumococcus  the  pus  is  thick  and  creamy 
in  appearance  and  the  prognosis  is  favorable.  When  due  to  grip 
infection,  to  the  streptococcus,  staphylococcus,  or  colon  bacillus, 
the  pus  is  thin  and  watery,  frequently  contains  flakes  of  fibrin,  and 
may  have  a  foul  odor.  In  these  cases  the  prognosis  is  more  grave. 
In  the  tuberculous  variety  the  pus  is  whitish,  thin,  and  contains 
30 


466 


DISEASES  OF   THORAX,   PLEURA,   AND  LUNG 


masses  of  caseous  material.  In  all  cases  the  parietal  and  visceral 
pleura  are  thickened  and  covered  with  a  fibrinous  exudate. 

Symptoms. — The  symptoms  of  a  non-tuberculous  empyema  often 
are  obscure  in  the  early  stages,  and  the  case  not  infrequently  is  regarded 
as  one  of  delayed  resolution  of  a  pneumonia.  Sooner  or  later,  however, 
there  will  be  more  or  less  dyspnea,  cough,  fever,  chills,  sweats,  a 
high  leukocytosis,  and  evidences  of  grave  toxemia.  In  the  tuberculous 
cases  the  onset  is  still  more  insidious.  While  cough  and  dyspnea  may 
be  present,  fever,  chills,  leukocytosis  and  acute  toxemia  are  absent. 

The  signs  arc  those  of  fluid  in  the  chest,  with  displacement  of 
the  heart  and  other  mediastinal  viscera.  In  many  cases  a  positive 
diagnosis  can  only  be  made  by  an  aspirating  syringe. 


Fig.  249. — Wilson's  empyema  drainage  tube. 


Treatment. — In  all  cases  of  non-tuberculous  empyema  the  treatment 
should  consist,  in  early  evacuation  of  the  pus  and  the  establishment 
of  adequate  drainage.  Thoracotomy  with  the  resection  of  one  or 
more  ribs  and  the  introduction  of  a  double  rubber  drainage  tube  or 
better  still  a  Wilson  double-flanged  drainage  tube  (Figs.  249  and  250) 
constitutes  the  best  routine  treatment.  In  adults  the  operation  can 
be  performed  with  cocaine.  In  children,  as  a  rule,  it  is  better  to  give  a 
small  amount  of  ether.  During  the  past  few  years  many  surgeons 
have  adopted  means  to  insure  continuous  suction  drainage  in  cases  of 
empyema.  This  when  successful  promotes  a  rapid  removal  of  the 
pus,  and  insures  a  prompt  expansion  of  the  compressed  lung  and 
shortens  to  considerable  extent  the  duration  of  after-treatment.  The 
simplest  of  these  is  by  means  of  a  Pollitzer  bag  attached  to  the  drain- 
age tube,  as  recommended  by  Bryant  (Fig.  251),  or  by  hydrostatic 


DISEASES  OF  THE   PLEURA 


467 


Fig.  250. — Wilson's  empyema  drainage  tube  in  position.     (Brewer,  in  Keen's  Surgery.) 


Fig  251. — Bryant's  empyema  drainage. 


468 


DISEASES  OF   THORAX,   PLEURA,  AND  LUNG 


pressure  by  means  of  two  Wolff  bottles.     To  insure  success  in  any 
method  of  suction  drainage,  the  tube  entering  the  chest  must  be  made 


Fig.  252. — Continuous  suction  drainage  by  siphonage. 


Fig.  253. — Brewer's  empyema  drainage  tube.     (Keen.) 


DISEASES  OF  THE  PLEURA  469 

air-tight.  This  is  best  accomplished  by  the  employment  of  the  author's 
double-flanged  tube  secured  by  adhesive  plaster  (Figs.  253  and  254). 
In  old  neglected  empyemas,  where  the  lung  will  not  expand  to 
fill  the  pleural  cavity,  one  of  several  methods  may  be  employed: 
First,  the  use  of  the  pneumatic  cabinet  to  forcibly  expand  the  lung: 


Fig.  254. — Brewer's  empyema  drainage  tube  in  place,  held  by  adhesive 
plaster.     (Keen.) 

second,  removal  of  the  fibrinous  envelope  which  encloses  the  lung  and 
prevents  expansion,  third,  plastic  operation  on  the  chest-wall  to 
enable  it  to  collapse  on  the  contracted  lung  and  fourth,  the  injection 
into  the  cavity  of  bismuth  paste  (1  part  of  arsenic-free  subnitrate 
of  bismuth,  and  2  parts  of  sterile  vaseline).     Several  injections  should 


470  DISEASES  OF   THORAX,   PLEURA,   AND  LUNG 

be  made  at  intervals  of  from  two  to  seven  days.  This  method, 
advised  by  Beck,  of  Chicago,  should  be  tried  in  all  cases  before 
resorting  to  the  graver  thoracoplasties. 

The  treatment  of  tuberculous  empyema  is  to  avoid  open  operation 
until  the  pus  points  on  the  chest-wall,  and  by  hygiene,  fresh  air,  good 
food,  and  tonics  to  improve  the  normal  resistance  of  the  patient.  In 
certain  rare  cases  where  dyspnea  constitutes  an  urgent  symptom, 
aspiration  of  the  pus  is  to  be  advised. 

The  treatment  of  the  interlobar  empyema  is  the  same  as  for  abscess 
of  the  lung. 

DISEASES  OF  THE  LUNG. 

Abscess  of  the  Lung. — This  condition  is  comparatively  rare.  It 
occurs  as  a  sequel  of  lobar  pneumonia,  in  which  case  the  abscess  is 
generally  single;  as  a  result  of  septic  bronchopneumonia,  in  which  case 
the  abscesses  may  be  numerous  and  scattered  throughout  both  lungs; 
as  a  result  of  tuberculosis,  foreign  body,  bronchiectasis,  or  pyemia. 
It  has  recently  been  shown  that  the  pneumonias  due  to  influenza  are 
more  frequently  complicated  with  abscess  of  the  lung  than  the  ordinary 
variety. 

Symptoms. — The  symptoms  of  abscess  of  the  lung  are  often  obscure. 
If,  following  a  lobar  pneumonia,  resolution  is  delayed  and  the  pulse 
and  temperature  remain  high,  chills,  sweats,  and  progressive  asthenia 
develop,  abscess  is  to  be  suspected.  The  signs  are  those  of  a  limited 
area  of  consolidation.  According  to  Tuffier's  statistics,  abscess  of  the 
lung  is  found  more  frequently  in  the  lower  than  the  upper  lobe,  and,  as 
a  rule,  nearer  the  posterior  surface.  As  the  physical  signs  frequently 
are  misleading,  a  positive  diagnosis  is  often  delayed  until  the  patient 
is  prostrated  by  prolonged  toxemia.  In  the  writer's  experience  the 
,r-rays  are  often  of  great  service  in  locating  a  focus.  Exploratory 
aspiration  often  is  necessary  to  establish  the  diagnosis.  When  the 
abscess  has  ruptured  into  a  bronchus,  the  presence  of  an  exceedingly 
pungent,  foul-smelling  expectoration  is  characteristic. 

In  these  cases  a  prolonged  paroxysm  of  coughing  is  apt  to  occur  in 
the  morning,  which  empties  the  cavity. 

Treatment. — The  treatment  of  abscess  of  the  lung  is  by  incision 
and  drainage.  An  incision  is  made  over  a  rib,  the  soft  parts  retracted, 
and  the  intercostal  muscle  divided,  exposing  the  parietal  layer  of  the 
pleura.  If  an  adhesion  exists  between  the  parietal  pleura  and  lung, 
the  former  will  appear  opaque;  if  no  adhesion  is  present,  the  pleura 
will  be  translucent  and  the  mottled  lung  will  be  seen  to  move  beneath 
it  (Keen).  If  adhesions  are  present,  a  director  may  be  gently  intro- 
duced into  the  lung,  and  when  pus  is  reached  the  opening  may  be 
enlarged  by  passing  a  closed  pair  of  dressing-forceps  along  the  groove 
of  the  director  and  withdrawing  them  partly  opened.  The  finger 
may  then  be  passed  into  the  wound  and  the  cavity  explored.  A 
drainage  tube  should  be  introduced  and  supported  by  gauze  packing. 


DISEASES  OF  THE  LUNG  471 

A  heavy  gauze  and  cotton  dressing  should  be  applied  and  the  wound 
dressed    as   infrequently   as   possible. 

If  there  is  no  adhesion  between  the  layers  of  the  pleura  and  the 
symptoms  are  not  urgent,  packing  the  wound  for  forty-eight  hours 
will  result  in  adhesions  forming,  leaving  a  space  through  which  the 
abscess  subsequently  may  be  opened  as  above.  If  the  symptoms  do 
not  warrant  such  delay,  the  pus  should  be  evacuated  at  once  and 
provision  made  for  drainage  of  the  pleural  cavity,  which  is  sure  to 
become  infected.  In  cases  where  the  abscess  ruptures  into  a  bronchus 
without  relief  of  symptoms,  the  question  of  external  drainage  should 
be  considered.  In  these  cases,  which  often  pursue  an  exceedingly 
chronic  course,  Murphy  believes  the  cause  of  delayed  resolution 
to  be  the  presence  of  adhesions  which  prevent  collapse  of  the  lung 
and  its  contained  cavity.  For  this  he  advises  thoracotomy,  the  intro- 
duction of  the  hand  into  the  pleural  cavity,  separation  of  the  adhesions, 
allowing  collapse  of  the  lung.  A  less  hazardous  operation  in  these 
cases  would  be  extrapleural  thoracoplasty  or  removal  of  a  sufficient 
number  of  ribs  without  opening  the  pleura,  to  allow  the  chest-wall 
to  collapse,  causing  shrinkage  of  the  lung  and  closure  of  the  abscess 
cavity.  Where  no  adhesions  exist  the  production  of  an  artificial 
pneumothorax  by  the  introduction  of  sterile  nitrogen  gas  into  the 
pleural  cavity  is  to  be  recommended. 

Prognosis. — The  prognosis  in  abscess  of  the  lung  is  always  grave. 
Single  abscesses  treated  in  the  manner  just  described  frequently 
recover.  In  cases  of  multiple  abscesses  of  metastatic  origin  surgical 
procedures  are  contra-indicated. 

Bronchiectasis. — Dilatation  of  the  bronchi  is  of  frequent  occurrence 
in  patients  suffering  from  chronic  cough.  In  the  majority  of  instances 
the  dilatations  are  fusiform,  multiple,  and  associated  with  an  abundant 
putrid  secretion.  These  cases  are  not  to  be  subjected  to  surgical 
treatment.  In  certain  rare  instances  there  exists  a  sacculated  dila- 
tation which  communicates  with  the  bronchus  by  a  narrow  opening. 
These  cases  strongly  resemble  chronic  abscess  of  the  lung,  and  often 
may  be  relieved  by  surgical  treatment. 

Symptoms. — The  symptoms  of  a  sacculated  bronchiectasis  are: 
morning  cough,  with  expectoration  of  a  large  amount  of  extremely 
fetid  pus,  followed  by  a  period  of  rest  until  the  cavity  refills.  Y\  ith 
this  there  is  a  loss  of  appetite  and  strength,  a  foul  breath,  more  or 
less  emaciation,  and  evidences  of  slowly  progressing  sepsis.  The 
physical  signs  are  those  of  a  cavity  when  the  sac  is  empty,  of  an  area 
of  consolidation  when  full.  The  .r-rays  are  often  of  value  in  locating 
the  focus. 

Treatment. — The  treatment  should  be  the  same  as  for  abscess  of 
the  lung  which  has  ruptured,  collapse  of  the  lung  by  the  introduction 
of  sterile  nitrogen  gas  in  the  pleural  cavity  where  no  adhesions  exist, 
extrapleural  thoracoplasty  where  adhesions  are  present  of  sufficient 
extent  to  prevent  collapse  of  the  lung.    In  certain  obstinate  cases  some 


472  DISEASES  OF   THORAX,   PLEURA,   AND  LUNG 

authorities  advise  freely  opening  the  pleural  cavity,  accurately  locating 
the  lesion  by  palpation,  separating  all  adhesions,  and  draining  both 
pulmonary  focus  and  the  pleural  cavity. 

Gangrene  of  the  Lung. — Pulmonary  gangrene  may  arise  from  the 
same  causes  as  abscess  of  the  lung.  It  occurs  generally  in  greatly 
debilitated  subjects,  and  is  often  associated  with  diabetes,  nephritis, 
alcoholism,  and  starvation.  In  the  majority  of  cases  it  follows  pneu- 
monia.   In  rare  instances  it  may  be  the  result  of  pulmonary  embolism. 

Symptoms. — The  symptoms  of  gangrene  of  the  lung  are  an  exceed- 
ingly foul  odor  to  the  breath,  followed  by  the  expectoration  of  a  large 
amount  of  dark-colored  material,  which,  if  allowed  to  stand  in  a 
glass,  will  appear  frothy  on  top  and  contain  at  the  bottom  of  the  glass 
shreds  and  masses  of  gangrenous  tissue.  Added  to  this,  there  is 
extreme  prostration,  often  with  a  subnormal  temperature  and  a  rapid, 
thready  pulse.  In  other  cases  the  temperature  may  be  elevated. 
Hemorrhages  may  occur,  and  in  some  instances  be  the  immediate 
cause  of  death. 

Prognosis. — The  prognosis  in  gangrene  of  the  lung  is  exceedingly 
grave.  Prior  to  the  employment  of  surgical  measures  the  mortality 
was  upward  of  80  per  cent.  In  cases  treated  surgically  the  death  rate 
is  between  30  and  40  per  cent. 

Treatment. — The  treatment  should  consist  in  freely  opening  the 
pleural  cavity,  locating  the  area  of  necrosis,  and  establishing  drainage 
by  generous  gauze-packing  until  the  slough  separates  spontaneously, 
after  which  it  should  be  removed  and  free  drainage  maintained  for 
the  infected  pleural  cavity. 

Actinomycosis  of  the  Lung. — While  the  primary  lesions  of  actino- 
mycosis occur  most  frequently  in  the  digestive  tract,  occasionally 
they  are  seen  in  the  lungs  as  a  result  of  aspiration  of  the  ray  fungus. 
Secondary  pulmonary  lesions,  however,  are  far  more  frequent,  and  are 
the  result  of  an  extension  of  the  disease  from  some  abdominal  focus. 

The  disease  in  the  lung  gives  rise  to  areas  of  consolidation  re- 
sembling tuberculosis.  Later  these  break  down,  forming  cavities 
with  an  excessive  formation  of  granulation  tissue.  The  pleura  and 
chest-wall  are  finally  invaded  with  the  formation  of  large  areas  of 
brawny  induration  of  the  skin  and  sinuses.  As  a  result  of  adhesions 
and  contraction  of  the  abundant  granulation  tissue,  retraction  of  the 
chest-wall  takes  place,  often  with  marked  deformity. 

Symptoms. — The  symptoms  of  pulmonary  actinomycosis  develop 
slowly.  There  are  pain,  cough,  moderate  fever,  and  loss  of  weight 
and  strength.  The  physical  signs  at  first  are  similar  to  those  of  tuber- 
culosis. The  diagnosis  can  only  be  established  by  observing  the  small 
yellow  masses  in  the  discharges,  which  upon  microscopic  examination 
reveal  the  ray  fungus. 

Treatment. — The  treatment  should  consist  in  opening  and  draining 
pus  cavities  and  the  administration  of  potassium  iodide  or  the  copper 
salts.    If  the  diagnosis  of  a  small  primary  focus  could  be  established 


DISEASES  OF  THE  LUNG  473 

early  radical  removal  by  pneumectomy  would  be  the  rational  treat- 
ment. 

Tuberculosis  of  the  Lung. — The  surgical  treatment  of  tuberculosis 
of  the  lung  has  recently  been  revived,  and  is  receiving  serious  attention. 
The  idea  of  completely  removing  a  small  isolated  focus  by  resection 
of  a  portion  of  the  lung  tissue  is  no  longer  advocated  by  surgeons, 
for  the  reason  that  the  mortality  of  such  a  procedure  is  high,  and  the 
results  no  better  than  those  which  can  be  obtained  by  the  open-air 
treatment  in  incipient  cases. 

The  idea  of  causing  a  collapse  of  the  lung  which  is  the  seat  of  a 
tuberculous  lesion  seems  to  be  more  rational.  Some  time  ago  Murphy 
reported  a  series  of  cases  in  which  considerable  benefit  was  obtained 
by  producing  an  artificial  pneumothorax  by  the  introduction  of  sterile 
nitrogen  gas  into  the  pleural  cavity,  and  recently  Forlanini,  Brauer 
and  others  have  reported  numerous  successful  cases  by  this  method. 

When  dense  adhesions  are  present  which  would  interfere  with  the 
complete  collapse  of  the  lung  by  the  nitrogen  injection,  Garre,  Quincke, 
and  others  have  advised  the  removal  of  several  ribs  over  a  tuberculous 
focus  to  allow  collapse  of  the  soft  tissues,  and  to  promote  thereby  a 
shrinkage  in  the  volume  of  the  lung  and  obliteration  of  the  cavity. 
Tuffier  has  recently  advised  and  successfully  practised  removal  of 
one  or  more  ribs,  stripping  the  parietal  pleura  from  the  chest  wall 
over  a  large  area,  and  filling  the  dead  space  thus  produced  with  masses 
of  fat.  Many  of  these  operations  have  been  followed  by  encouraging 
results. 

Friedrich,  of  Marburg,  has  recently  advised  far  more  extensive 
resections,  allowing  complete  collapse  of  the  lung  on  one  side.  His 
operation  consists  in  raising  an  enormous  musculocutaneous  flap 
from  below  upward,  exposing  the  ribs  from  the  second  to  the  tenth. 
These  are  next  resected  from  their  cartilage  to  the  spine,  the  posterior 
layer  of  periosteum  being  left  adherent  to  the  intact  pleura.  This 
procedure  results  in  the  immediate  complete  collapse  of  the  lung. 
The  large  flap  is  then  replaced  and  sutured,  and  an  aseptic  dressing 
applied. 

While  this  formidable  operation  would  seem  almost  too  hazardous 
in  the  advanced  cases  in  which  he  considers  it  indicated,  he  reports 
that  70  per  cent,  of  the  unilateral  cases  survive  the  operation  and  show 
marked  improvement  in  symptoms. 

While  sufficient  data  are  not  yet  available  to  enable  one  to  form 
an  opinion  regarding  the  usefulness  of  these  procedures,  the  principle 
that  collapse  of  a  tuberculous  lung  favors  resolution  seems  to  have 
been  established. 

Pulmonary  Emphysema. — Freund,  of  Berlin,  has  recently  called 
attention  to  the  fact  that  in  certain  cases  of  alveolar  emphysema  the 
symptoms  are  due  to  an  abnormal  ridigity  of  the  chest -wall.  This 
rigidity  he  believes  to  be  caused  by  calcification  and  other  pathologic 
changes  in  the  costal  cartilages  resulting  in  a  diminution  in  their 


474  DISEASES  OF   THORAX,   PLEURA,  AND  LUNG 

normal  elasticity.  These  changes  have  been  noted  more  particularly 
in  the  second  and  third  cartilages  on  the  right  side,  but  they  may  be 
present  in  any  or  all  of  these  structures. 

Acting  upon  the  suggestion  furnished  by  these  observations,  Hilde- 
brand,  Haasler,  and  other  German  surgeons  have  resected  two  or  more 
costal  cartilages  on  one  or  both  sides.  This  allowed  a  greater  excursion 
of  the  corresponding  ribs  during  the  respiratory  movements  and  gave 
considerable  relief  to  the  dyspnea. 

Goodman  has  recently  reported  four  cases  treated  at  the  Monte- 
fiore  Home  by  this  method  with  encouraging  results.  While  the  opera- 
tion cannot  be  expected  to  cure  the  lung  lesion,  it  is  reasonable  to 
suppose  that  considerable  relief  may  be  expected  in  suitable  cases. 
To  insure  the  best  results  the  perichondrium  should  be  completely 
removed,  as  several  cases  of  recurrence  have  been  reported  where  this 
precaution  has  been  neglected. 

Gummatous  Infiltration  of  the  Lung. — Gummatous  infiltration  of 
the  lung  occurs  as  a  late  lesion  of  syphilis.  The  symptoms  are  by  no 
means  characteristic.  The  gummata  may  break  down  and  form 
cavities  similar  to  those  due  to  tuberculosis,  the  difference  being  that 
the  former  are  often  greatly  improved  by  antisyphilitic  treatment. 

NEW  GROWTHS  OF  THE  PLEURA  AND  LUNG. 

Tumors  arising  from  the  pleura  are  rare.  The  one  most  frequently 
observed  is  endothelioma,  which  grows  slowly,  and  often  without 
symptoms  until  it  gives  rise  to  dyspnea  by  encroaching  on  the  lung 
space.  Occasionally  it  causes  a  pleural  exudate.  Sarcotna,  which  is 
rare,  grows  rapidly,  and  is  generally  associated  with  a  bloody  serous 
exudate. 

The  physical  signs  of  these  growths  are  those  of  fluid  in  the  chest; 
flatness,  absence  of  respiratory  sounds,  and  fremitus.  In  sarcoma, 
Warthin  states  that  atypic  cells  with  mitotic  figures  sometimes  can 
be  demonstrated  in  the  fluid. 

Primary  carcinoma  and  sarcoma  may  occur  in  the  lung,  the  former 
being  most  frequently  encountered. 

The  symptoms  of  a  primary  malignant  tumor  of  the  lung  are: 
an  afebrile  cough,  with  an  area  of  rapidly  advancing  consolidation, 
followed  later  by  dyspnea,  bloody  expectoration,  a  hemorrhagic 
pleural  exudate,  and  a  rapidly  advancing  cachexia.  The  occurrence 
of  these  symptoms  in  an  individual  who  has  already  a  carcinomatous 
or  sarcomatous  focus  elsewhere  in  the  body  is  sufficient  to  justify 
the  diagnosis  of  a  secondary  malignant  process  in  the  lung.  Seydel, 
who  recently  published  an  interesting  analysis  of  lung  tumors  from 
the  autopsy  records  of  the  Munich  Institute,  states  that  of  the  primary 
sarcomata  and  carcinomata  73  per  cent,  of  the  former  and  90  per  cent, 
of  the  latter  were  clearly  inoperable.  No  case  of  solid  benign  tumor 
of  the  lung  was  found  in  the  10,829  autopsy  reports  analyzed. 


DISEASES  OF  THE  MEDIASTINUM  475 

Treatment.— It  early  diagnosis  of  a  primary  malignant  tumor  of 
the  lung  can  be  made,  pneumectomy  is  indicated. 
Echinococcus   Cysts.— Echinococcus  cysts   occur   more   frequently 

in  the  lung  than  in  any  other  organ  of  the  body  except  the  liver.  The 
disease,  however,  is  rare  in  the  United  States,  most  of  the  cases  occur- 
ring in  immigrants  or  those  who  have  visited  foreign  countries. 

Symptoms.  The  symptoms  of  echinococcus  disease  of  the  lung 
are  mainly  those  of  pressure,  dyspnea,  displacement  of  the  heart, 
and  other  mediastinal  structures,  cough,  bulging  of  the  chest,  and 
a  dislocation  downward  of  the  liver.  The  signs  are  those  of  an  intra- 
thoracic tumor.  In  the  diagnosis  of  this  condition,  marked  eosino- 
philia,  the  reaction  of  fixation  of  complement,  the  physical  signs  of  an 
intrathoracic  tumor  and  the  x-rays  are  the  most  important  factors. 
The  .r-ray  shadow  should  be  round,  with  well-defined  borders,  and 
without  evidences  of  an  infiltrating  lesion. 

Prognosis. — The  prognosis  in  this  condition  is  grave  if  untreated, 
as  rupture  may  take  place  into  a  bronchus  and  cause  asphyxia,  or 
the  fluid  may  become  infected  and  cause  a  fatal  toxemia. 

Treatment. — The  treatment  should  consist  in  marsupialization 
or  stitching  the  cyst-wall  to  the  external  wound  for  continuous  drain- 
age. Occasionally  it  may  be  possible  to  remove  the  inner  or  secreting 
layer  of  the  sac. 

DISEASES  OF  THE  MEDIASTINUM. 

Injuries  of  the  mediastinal  structures  are  rare,  except  in  fractures 
of  the  spine  or  crushes  of  the  chest-wall.  When  the  heart  and  great 
vessels  are  injured  death  results  so  rapidly  that  little  or  nothing  can 
be  done.  Hemorrhage  into  the  mediastinal  space,  when  not  due  to 
injury  of  the  large  vessels,  is  seldom  serious,  and  if  uninfected  is  quickly 
absorbed.  Gunshot  wounds  may  injure  the  trachea,  bronchi,  or 
esophagus,  giving  rise  to  emphysema  or  septic  inflammation.  Medias- 
tinal emphysema  extends  rapidly  to  the  root  of  the  neck  and  from 
there  spreads  in  any  direction.  It  may  give  rise  to  grave  dyspnea 
from  pressure  on  the  heart  and  great  vessels.  The  condition  sometimes 
can  be  relieved  by  making  an  incision  into  the  cellular  plane  just 
above  the  suprasternal  notch  and  applying  a  Bier  cup. 

Acute  Mediastinal  Cellulitis. — Acute  mediastinal  cellulitis  may 
arise  as  a  result  of  trauma,  osteomyelitis  of  the  spine  or  sternum, 
infection  by  the  lymphatics,  or  by  an  extension  downward  of  a  cellulitis 
of  the  neck.  It  is  most  frequently  located  in  the  upper  and  anterior 
portion  of  the  space,  30  out  of  36  cases  reported  by  Hare  being  located 
in  that  region. 

Symptoms. — The  symptoms  are  deep-seated  pain  and  tenderness 
over  the  sternum,  fever,  leukocytosis,  and  evidences  of  grave  toxemia. 
Later,  the  pus  may  point  at  the  root  of  the  neck,  by  the  side  of  the 
ensiform  or  between  the  costal  cartilages. 


476 


DISEASES  OF   THORAX,   PLEURA,   AXD  LUNG 


Treatment. — The  treatment  at  first  should  be  by  local  applications 
of  cold  and  measures  to  increase  the  normal  resistance.  If  signs  of 
suppuration  appear,  the  sternum  should  be  trephined  and  an  effort 
made  to  locate  and  evacuate  the  pus. 

NEW  GROWTHS  OF  THE  MEDIASTINUM. 

Both  benign  and  malignant  tumors  may  occur  in  the  mediastinum. 
The  latter  are  more  frequent,  the  proportion  being  four  to  one.  Of 
the  benign  growths  may  be  mentioned  lipomata,  fibromata,  dermoid 
and  echinococcus  cysts.     Of  the  malignant,  sarcoma  and  carcinoma. 


Fig.  255. — Dilated  veins  of  head  and  neck  from  mediastinal  tumor. 


With  the  exception  of  the  cysts,  benign  tumors  rarely  give  rise 
to  symptoms  requiring  surgical  interference.  Primary  carcinoma 
may  develop  from  the  remains  of  the  thymus  gland.  Primary  sarcoma 
occurs  most  frequently  in  the  lymph  nodes  and  is  exceedingly 
malignant.     Lymph-node  tumors  of  Hodgkin's  disease  are  rare. 

Secondary  malignant  growths  are  not  infrequent. 

Symptoms.— The  symptoms  of  a  mediastinal  tumor  are  pain, 
cyanosis,  and  dilatation  of  the  veins  of  the  face  and  neck,  dyspnea, 
and  in  some  cases  a  unilateral  or  bilateral  edema  of   the  chest-wall 


OPERATIONS   UPON   THE  THORAX  477 

from  azygos  pressure  (Fig.  2.").")).  The  .r-rays  may  reveal  shadows 
which  will  aid  the  diagnosis. 

Treatment. — The  treatment  should  at  first  be  an  exploratory  trephine 
opening  through  the  sternum,  which  later  can  be  cautiously  enlarged 
with  a  view  to  exposing  the  growth. 

Extirpation  of  accessible  tumors,  enucleation  or  drainage  of  cysts, 
or  simply  the  removal  of  pressure  by  a  wide  resection  of  the  bone  would 
constitute  the  most  rational  treatment.  In  inoperable  malignant 
growths  the  .r-rays  may  cause  a  diminution  in  the  pressure  symp- 
toms and  in  some  instances  an  actual  diminution  of  the  size  of  the 
tumor  has  been  observed. 

OPERATIONS  UPON  THE  THORAX. 

Paracentesis. — This  operation  is  indicated  for  the  removal  of  an 
effusion,  fluid  blood,  or  air  from  the  pleural  cavity.  It  consists  in  the 
introduction  of  an  aspirating  needle  through  the  chest-wall  at  a  point 
where  the  physical  signs  indicate  the  presence  of  fluid. 

When  the  fluid  is  not  encapsulated,  but  free  in  the  pleural  sac, 
the  site  selected  is  usually  in  the  postaxillary  line  through  the  eighth 
or  ninth  intercostal  space.  The  region  is  prepared  in  the  usual 
manner,  and  a  sterile  needle  thrust  through  the  chest  just  above  the 
upper  border  of  a  rib  to  avoid  wounding  the  intercostal  vessels.  Xo 
anesthetic,  as  a  rule,  is  required.  "When  the  needle  is  felt  to  be  within 
the  pleural  cavity  the  aspirating  tube  is  attached  and  the  fluid  with- 
drawn. The  small  wound  is  afterward  sealed  with  collodion  or  covered 
with  a  strip  of  sterile  adhesive  plaster. 

The  Establishment  of  an  Artificial  Pneumothorax. — This  procedure 
is  indicated  when  for  any  reason  it  is  desirable  to  produce  a  contraction 
of  the  lung. 

A  sterile  trocar  is  introduced  through  the  soft  tissues  down  to  a 
rib.  The  needle  is  then  withdrawn  and  the  canula  connected  with 
a  reservoir  of  sterile  nitrogen  gas  by  means  of  a  rubber  tube.  The 
canula  is  then  pushed  upward  above  the  rib  and  thrust  into  the 
pleural  cavity.  When  this  is  reached  the  gas  will  flow  into  the  pleura 
and  gradually  compress  the  lung.  From  500  to  2000  c.crn.  of  the 
gas  may  be  introduced. 

A  pneumothorax  thus  created  will  often  last  for  from  three  to 
five  months. 

Thoracotomy. — Thoracotomy,  or  creating  an  opening  through  the 
chest-wall  with  a  view  to  draining  the  pleural  cavity,  may  be  accom- 
plished by  an  incision  between  the  ribs,  or  a  portion  of  one  or  more 
ribs  may  be  resected.  The  latter  plan  is  the  one  generally  adopted 
when  the  object  is  to  evacuate  and  permanently  drain  an  empyema. 
In  an  encysted  empyema  the  opening  should  be  established  over 
the  lowest  part  of  the  collection;  in  an  ordinary  empyema  the 
incision  should   be  between  the  seventh  and  tenth  ribs,  depending 


478 


DISEASES  OF   THORAX,   PLEURA,   AND   LUNG 


upon  the  amount  of  fluid  and  the  position  of  the  diaphragm.  A 
point  should  be  selected  just  posterior  to  the  anterior  axillary  line, 
and  an  incision  made  midway  between  two  ribs,  dividing  the  tissues 
down  to  the  pleura,  which  may  be  opened  with  a  knife  or  by  puncture 
with  a  director  and  subsequent  dilatation.  If  a  portion  of  a  rib  is  to 
be  resected,  the  incision  should  be  made  directly  over  the  bone  and 


^v  V  ^F 

P  ^\ 

v^tS|jS|^, 

Hl^? 

^Sff^W-           Wm. 

'•^%         vfl                               3r  j    ;rir 

/      0 

e3S2e«I 

Fig.  256. — Resection  of  ribs  for  empyema.     (Brewer,  Keen's  Surgery.) 

carried  through  the  periosteum.  The  soft  parts  are  to  be  scraped 
from  the  bone  by  a  raspatory  or  periosteum  elevator,  care  being  taken 
to  keep  close  to  the  bone  in  order  to  remove  the  periosteum  completely 
from  its  posterior  and  inferior  aspects.  This  prevents  wounding  the 
intercostal  vessels.  When  the  bone  is  cleared,  it  is  cut  by  bone-forceps 
or  a  Gigli  saw,  and  a  piece  from  one  to  three  inches  in  length  removed 


OPERATIONS   UPON   THE   THORAX  479 

(Fig.  256).  After  all  hemorrhage  is  arrested  the  opening  into  the 
pleural  sac  may  be  made  as  above  described  and  the  pus  evacuated. 
Two  drainage  tubes  tied  together  should  then  be  introduced,  or  the 
double-flanged  rubber  drainage  tube  suggested  by  Wilson.  If  ordinary 
tubes  are  used,  they  should  be  introduced  only  far  enough  to  insure 
drainage,  as  long  tubes  passed  into  the  costodiapbragmatic  sinus  are 
a  source  of  irritation,  and  not  infrequently  cause  deep,  slowly  healing 
sinuses.  The  pleural  cavity  should  not  be  irrigated  except  to  effect 
removal  of  large  masses  of  fibrin.  A  large  absorbent  dressing  should 
be  applied  and  the  dressings  changed  only  when  saturated  with  the 
discharge. 

In  the  majority  of  instances  this  operation  is  performed  best  under 
general  anesthesia.  .  Local  anesthesia  should  be  employed  if  the 
respiration  is  seriously  embarrassed  or  the  condition  of  the  patient 
does  not  permit  the  use  of  ether  or  chloroform. 

When  a  more  extensive  exposure  of  the  thoracic  cavity  is  required, 
as  for  decortication  of  the  lung,  pneumectomy,  or  operations  on  the 
thoracic  portion  of  the  esophagus,  complete  removal  of  one  or  more 
ribs  with  wide  retraction  of  the  wound  affords  ample  room  for  all 
ordinary  procedures. 

Thoracoplasty. — Thoracoplasty  consists  in  a  resection  of  several 
ribs  to  enable  the  rigid  chest-wall  to  collapse  upon  a  contracted  lung, 
and  thus  to  obliterate  a  suppurating  dead  space.  It  is  indicated  in 
old  empyemas  which  will  not  heal,  and  has  recently  been  recommended 
to  allow  contraction  of  the  lung  for  the  purpose  of  obliterating  tuber- 
culous or  other  chronic  cavities  in  which  openings  into  a  bronchus 
have  been  established. 

Estlander's  operation  for  chronic  empyema  consists  in  the  removal 
of  portions  of  several  ribs,  according  to  the  size  and  shape  of  the 
underlying  cavity,  but  without  disturbing  the  thickened  parietal 
pleura.  This  may  be  accomplished  by  raising  a  large  flap  of  skin 
and  muscle,  thereby  exposing  four  or  five  ribs  from  their  angles  to 
their  attachments  to  the  costal  cartilage.  The  ribs  are  then  resected 
as  described  above  and  the  relaxed  chest-wall  pressed  firmly  down 
upon  the  lung.  The  original  opening  into  the  pleural  sac  should  be 
enlarged,  the  cavity  curetted,  injected  with  hydrogen  peroxide,  and 
irrigated  with  sterile  salt  solution. 

Schede's  operation  consists  in  removing  not  only  the  ribs,  but  also 
the  thickened  parietal  pleura.  He  advises  a  large  U-shaped  incision 
beginning  near  the  junction  of  the  second  rib  and  costal  cartilage, 
extending  downward  and  backward  to  the  tenth  rib,  then  upward  to 
the  upper  posterior  angle  of  the  scapula.  The  skin  and  superficial 
muscles  are  separated  from  the  chest-wall  and  drawn  upward,  carrying 
the  scapula  with  them.  The  ribs,  from  the  second  to  the  lowest  limit  of 
the  pleural  sac,  are  then  removed  with  heavy  bone-forceps  and  scissors, 
and  with  them  the  intercostal  muscles  and  thickened  pleura.  The 
large  skin  and  muscle  flap  is  then  replaced,  sutured,  and  pressed 


480  DISEASES  OF   THORAX,   PLEURA,  AND  LUNG 

firmly  against  the  collapsed  lung.  The  operation  is  a  dangerous  one, 
and  should  not  be  attempted  unless  the  surgeon  is  provided  with  an 
adequate  number  of  competent  assistants  and  every  facility  for  meeting 
and  controlling  severe  hemorrhage  and  profound  shock. 

Friedrich's  operation  for  the  cure  of  pulmonary  tuberculosis  is 
the  same  as  Schede's,  except  that  the  resection  of  the  ribs  is  a  sub- 
periosteal resection,  the  pleural  cavity  not  being  opened. 

Osteoplastic  Resection  of  the  Chest-wall. — This  operation  is  under- 
taken for  exploratory  purposes,  operations  on  the  heart  and  peri- 


Fiu.  257. — Osteoplastic  thoracotomy.     (Brewer,  Keen's  Surgery.) 

cardium,  for  the  removaljof  tumors  of  the  lung  and  pleura,  for  the 
removal  of  foreign  bodies  in  the  bronchi  and  esophagus,  and  for  the 
treatment  of  empyema  by  the  Fowler  method. 

An  incision  is  made  parallel  with  the  median  line  of  the  body, 
about  one  inch  from  the  sternum,  exposing  the  costal  cartilages  of 
four  or  five  ribs.  From  either  extremity  of  this  incision  two  others 
are  made  outward  over  the  intercostal  spaces.  The  costal  cartilages 
are  divided  with  bone-forceps,  the  intercostal  vessels  doubly  ligated 
and  cut,  the  incisions  carried  through  the  entire  chest-wall,  and  the 
rectangular  flap  raised  and  bent  outward,  breaking  the  ribs  at  the 


OPERATIONS   UPON  THE  THORAX  IS] 

Junction  of  the  flap  with  the  healthy  chest-wall  (Fig.  257).  When 
the  necessary  intrathoracic  procedures  have  been  carried  out  the 
flap  is  returned  and  sutured  in  place  with  or  without  drainage.  A 
similar  Hap  may  be  made  in  any  part  of  the  chest. 

Decortication  of  the  lung,  or  Fowler's  operation  for  empyema,  con- 
sists in  exposing  the  retracted  lung  through  an  osteoplastic  opening 
in  the  chest,  incising  the  thickened  layer  of  visceral  pleura,  stripping 
it  from  the  surface  of  the  lung,  and  removing  it  with  scissors.  In 
children  this  often  results  in  immediate  expansion  of  the  lung,  often 
to  a  degree  which  nearly  fills  the  pleural  cavity.  In  adults  it  is  rarely 
as  satisfactory.  It  should  be  advised  at  an  early  period  before  inter- 
stitial changes  have  occurred  in  the  lung  to  prevent  its  expansion. 

Pneumectomy. — This  operation,  which  consists  in  removal  of  a 
portion  of  the  lung,  is  occasionally  undertaken  in  extensive  wounds  or 
laceration  of  the  organ,  for  the  removal  of  malignant  growths,  or,  rarely, 
in  tuberculosis  or  gangrene.  The  chest  is  opened  by  the  osteoplastic 
method  or  by  complete  resection  of  one  or  more  ribs.  The  affected 
portion  of  the  lung  is  next  delivered  through  the  wound,  transfixed 
and  securely  ligated,  after  which  the  diseased  area  is  removed.  Nathan 
Green  surrounds  the  lung  above  the  portion  to  be  removed  by  a 
subpleural  ligature  of  silk  or  heavy  chromic  catgut,  and  after  the  distal 
portion  has  been  excised,  sutures  the  pleural  edges  together  by  a 
continuous  suture  of  plain  catgut. 

After  either  procedure  the  stump  is  replaced  within  the  pleural 
cavity  and  the  thorax  wound  closed  with  or  without  drainage. 

Anterior  Mediastinal  Thoracotomy. — The  structures  in  the  anterior 
mediastinum  can  be  exposed  by  the  operation  of  Milton,  which 
consists  in  a  median  longitudinal  section  of  the  sternum,  with  separation 
of  the  two  halves.  Another  method  is  to  make  an  osteoplastic  resection 
of  a  rectangular  portion  of  the  sternum,  dividing  the  cartilages  along 
one  side,  sawing  transversely  through  the  sternum  above  and  below, 
and  turning  the  flap  to  the  opposite  side,  breaking  the  cartilages 
beneath  the  cutaneous  pedicle.  In  these  operations  the  greatest  care 
should  be  exercised  to  avoid  wounding  the  pleura,  the  internal  mam- 
mary artery,  or  the  great  vessels  issuing  from  the  base  of  the  heart. 

Posterior  Mediastinal  Thoracotomy. — By  this  operation  access  to 
the  posterior  mediastinum,  is  possible  for  evacuation  of  collections  of 
pus,  or  the  removal  of  foreign  bodies  in  the  bronchi.  A  rectangular 
musculocutaneous  flap  is  raised,  portions  of  two  or  three  ribs  re- 
sected, and  the  pleura  carefully  stripped  from  the  posterior  wall  and 
bodies  of  the  vertebra?,  after  which  the  posterior  mediastinal  space 
is  exposed  by  carefully  retracting  the  pleural  sac  outward. 

Methods  of  Avoiding  the  Dangers  of  Pneumothorax  in  Operations 
Upon  the  Lung  and  Mediastinal  Organs. — While  an  uncomplicated 
unilateral  pneumothorax  is  not  a  source  of  grave  danger  to  an  individual 
with  a  sound  lung  on  the  opposite  side,  when  such  a  pneumothorax 
is  associated  with  a  serious  operation  upon  the  lung  or  one  of  the 
31 


482  DISEASES  OF   THORAX,   PLEURA,   AND  LUNG 

mediastinal  structures,  it  adds  greatly  to  the  operative  risk.  When 
both  pleural  cavities  are  opened  the  result  is  generally  fatal. 

To  avoid  the  serious  consequences  of  operative  pneumothorax, 
many  methods  have  been  devised,  including  the  negative  pressure 
cabinet  of  Sauerbruch,  the  elaborate  operating  chamber  of  Willy 
Meyer  by  which  both  negative  and  positive  pressure  can  be  employed, 
and  the  portable  positive  pressure  cabinet  of  Janeway  and  Green. 

By  far  the  simplest  and  safest  is  the  intratracheal  insufflation 
method  of  anesthesia  devised  by  Meltzer  and  Auer. 

A  number  30  gum-elastic  woven  catheter  is  introduced  through  the 
glottis  well  down  into  the  trachea.  Through  this  a  current  of  air  is 
passed  by  means  of  a  foot-bellows,  and  rubber  tube  which  is  attached 
to  the  proximal  end  of  the  catheter.  By  this  simple  apparatus,  artificial 
respiration  can  be  kept  up  for  many  hours  without  any  muscular 
effort  on  the  part  of  the  patient.  If  the  air  from  the  bellows  is  passed 
through  a  Wolff  bottle  containing  ether,  before  entering  the  catheter, 
an  ideal  anesthesia  is  induced,  and  at  the  same  time  any  degree  of 
intrapulmonary  pressure  may  be  produced  and  maintained  by  regulat- 
ing the  amount  of  air  and  ether  vapor  entering  the  trachea  in  a  given 
time.  By  the  employment  of  this  method  of  anesthesia,  one  or  both 
pleural  cavities  may  be  opened  in  operative  approach  to  any  of  the 
intrathoracic  viscera  without  danger  of  any  of  the  untoward  effects 
of  pneumothorax. 

A  number  of  apparatus  have  been  devised  for  intratracheal  anesthesia 
with  a  view  to  regulating  more  accurately  the  intrapulmonary  pressure 
and  the  percentage  of  ether  vapor,  filtering  the  air  and  furnishing  it 
with  a  certain  amount  of  heat  and  moisture.  The  apparatus  of  Elsberg 
and  that  of  Janeway  are  in  general  use  and  have  proved  most  satis- 
factory. The  latest  and  perhaps  the  most  accurate  of  all,  however, 
is  the  one  recently  devised  by  Karl  Connell  which  is  described  on 
p.  162. 


CHAPTER  XIX. 

MALFORMATIONS  AND  DISEASES  OF  THE  MAMMARY 

GLAND. 

MALFORMATIONS  OF  THE  BREAST. 

Congenital  absence  of  the  breast  (amastia)  is  rare,  and  is  usually 
associated  with  other  anomalies,  as  absence  of  the  pectoral  muscles, 
or  abnormalities  in  the  development  of  the  ribs.  Supernumerary 
breasts  {polymastia)  are  more  common  and  are  observed  in  both 
males  and  females.  As  a  rule  these  aberrant  masses  of  gland  tissue 
occur  along  a  line  drawn  from  the  anterior  border  of  the  axilla  to  the 
middle  of  Poupart's  ligament,  although  they  have  been  observed 
on  the  buttock,  vulva,  and  thigh.  Occasionally  these  glands  present 
rudimentary  nipples  and  they  have  been  known  to  secrete  milk  during 
late  pregnancy  and  lactation.  The  normal  breast  tissue  often  extends 
upwards  toward  the  axilla,  and  if  enlarged  may  be  mistaken  for  a 
supernumerary  breast. 

DISEASES  OF  THE  MAMMARY  GLAND. 

Acute  Mastitis. — This  is  a  septic  inflammation  of  the  glandular 
and  areolar  tissue  of  the  breast.  It  may  occur  in  either  sex,  but  is 
far  more  common  in  women.  Although  acute  mastitis  may  arise  from 
wounds  and  other  traumata,  and  from  infection  conveyed  from 
other  parts  by  means  of  the  bloodvessels  or  lymphatics,  in  the  great 
majority  of  instances  the  disease  arises  in  nursing  women,  and  is  due 
to  infection  of  the  milk  ducts  from  an  inflamed  and  fissured  nipple. 

Symptoms. — The  symptoms  of  acute  mastitis  are  pain,  tenderness, 
and  an  increased  sense  of  weight  and  heat  in  the  breast,  with  superficial 
redness  and  edema  of  the  skin.  On  palpation  one  or  more  hard, 
tender  lumps  may  be  felt  in  the  breast;  or  the  entire  gland  may, 
rarely,  be  the  seat  of  a  massive  induration.  Often  there  is  a  chill 
at  the  beginning  of  the  infection,  with  elevation  of  temperature  and 
pulse  rate,  localized  pain  and  a  general  feeling  of  malaise.  The  occur- 
rence of  indurated  areas  in  the  breast  of  a  nursing  woman  without  fever 
or  other  evidences  of  constitutional  disturbance  is  frequently  ob- 
served, and  is  due  to  an  oversecretion  of  milk  which  is  not  regularly 
removed  by  the  nursing  infant.  In  these  cases  massage,  hot  applica- 
tions, and  the  use  of  the  breast  pump  will  cause  the  indurations  to 
disappear,  and  the  secretion  soon  accommodates  itself  to  the  needs 


484  DISEASES  OF   THE  MAMMARY  GLAND 

of  the  child.  If,  however,  this  "caking  of  the  breast"  is  neglected, 
if  often  gives  rise  to  genuine  mastitis. 

Acute  septic  mastitis  may  in  some  instances  under  early  appropriate 
treatment  subside,  the  individual  areas  gradually  disappear,  and  the 
breast  tissue  return  to  its  normal  condition.  In  most  cases,  however, 
the  disease  progresses,  and  suppuration  occurs  in  one  or  more  regions  in 
the  gland.  If  the  suppuration  is  superficial,  it  is  indicated  by  a  deep- 
red  or  purple  discoloration  of  the  skin,  which  is  raised  and  presents  an 
area  of  softening  and  fluctuation.  If  the  suppuration  occurs  deep 
in  the  tissue  of  the  breast,  these  signs  may  be  wanting.  The  presence 
of  pus  is  indicated  by  continued  pain,  fever,  chills,  sweats,  a  leucocytosis 
and  a  failure  of  the  induration  to  subside  after  a  reasonable  time.  If 
the  suppuration  takes  place  beneath  the  breast — submammary  abscess 
— the  entire  gland  is  raised  as  if  on  a  water-bed  and  is  abnormally 
movable  on  the  chest  wall,  fluctuation  often  can  be  detected  around 
the  periphery  of  the  gland,  and  occasionally  by  placing  a  hand  on 
either  side  of  the  breast  a  wave  of  fluid  may  be  appreciated  beneath 
the  gland. 

Treatment. — In  the  early  stages,  hot  fomentations  applied  every 
three  or  four  minutes  for  half  an  hour,  three  or  four  times  in  the  course 
of  the  day,  with  rest  in  bed,  saline  cathartics,  and  removal  of  the  breast 
milk,  occasionally  will  cause  the  symptoms  to  disappear.  If  the  disease 
progresses  and  suppuration  occurs,  nursing  should  be  stopped  and  the 
pus  evacuated  early  by  free  incisions  radiating  from  the  nipple  to 
avoid  cutting  the  large  milk  ducts.  Several  incisions  often  are  neces- 
sary, and  when  the  abscesses  are  deep  the  intervening  tissue  should 
be  broken  down  by  the  finger,  the  cavity  freely  irrigated,  treated 
with  hydrogen  peroxide,  packed  with  sterile  gauze,  or  drained  with 
rubber  tubes.  The  use  of  Bier's  suction  cups  in  acute  abscess  of  the 
breast  is  often  of  the  greatest  service,  as  it  enables  the  surgeon  to  make 
smaller  incisions,  frequently  does  away  with  the  necessity  of  drainage- 
tubes  or  packing,  and  shortens  the  duration  of  treatment.  If  the 
suppuration  is  beneath  the  breast,  the  incisions  should  be  made 
around  the  periphery.  It  occasionally  occurs  that  a  breast  may  be  so 
completely  destroyed  by  suppuration  and  the  resistance  of  the  indi- 
vidual so  reduced  by  the  prolonged  toxemia  that  complete  removal  of 
the  gland  is  necessary. 

Mastitis  Neonatorum. — The  breasts  of  newborn  infants  occasionally 
are  enlarged  and  present  the  signs  of  a  subacute  inflammation.  The 
condition  is  unimportant  as  they  never  suppurate  unless  irritated 
or  are  infected  as  a  result  of  careless  treatment. 

Mastitis  Adolescentium. — Swelling,  induration,  and  redness  may 
occur  about  the  nipple  and  areola  at  puberty  in  both  male  and  female 
children.  The  condition  is  not  due  to  infection  and  subsides  sponta- 
neously in  a  few  weeks  or  months. 

Chronic  Mastitis. — Chronic  mastitis  occurs  in  two  forms,  one  fol- 
lowing an  acute  attack  of  the  disease,  and  one  arising  independently 
of  infection. 


DISEASES  OF  THE  MAMMARY  GLAND  is.", 

In  the  first  variety,  after  an  acute  or  subacute  mastitis  with  or 
without  suppuration,  more  or  less  extensive  areas  of  induration  may 
persist  for  years  after  disappearance  of  the  acute  symptoms,  some- 
times causing  neuralgia  and  pain  from  the  pressure  of  clothing.  Occa- 
sionally the  pain  and  discomfort  in  these  eases  are  extreme,  and  often 
they  are  aggravated  at  the  menstrual  epoch. 

In  the  second  variety,  chronic  interstitial  mastitis,  the  entire  breast 
may  be  affected  by  an  overgrowth  of  the  interstitial  fibrous  tissue, 
which  is  associated  with  a  general  atrophy  of  the  glandular  substance. 
In  these  cases  the  breast  feels  lumpy  on  palpation,  and  numerous 
indurated  areas  are  present,  usually  oblong  and  fusiform  in  shape, 
running  from  the  periphery  toward  the  nipple.  This  condition  in 
reality  is  only  an  exaggerated  type  of  the  normal  fibrosis  and  glandular 
atrophy  of  the  menopause. 

There  is  a  growing  belief  among  surgeons  that  the  chronic  irritation 
of  chronic  mastitis  of  the  localized  indurated  type,  favors  the  subse- 
quent development  of  malignant  disease  in  a  breast. 

Treatment. — In  all  cases  in  which  doubt  exists  regarding  the  nature 
of  a  hard  nodule  in  the  breast  it  should  be  removed  and  subjected 
to  microscopic  examination. 

Galactocele. — A  galactocele  is  an  oval  cystic  tumor  filled  with 
milk.  Formerly  it  was  thought  to  be  a  distended  milk  duct  due  to 
occlusion  of  its  lumen,  but  later  histologic  study,  which  fails  to  show 
the  presence  of  epithelium  in  the  cyst  wall,  tends  to  confirm  the  view 
of  Lecene  that  it  is  a  chronic  abscess  cavity  into  which  milk  ducts 
have  opened.  While  these  tumors  occur  most  frequently  near  the 
nipple,  they  may  be  found  in  any  part  of  the  gland.  In  the  majority 
of  instances  they  develop  during  lactation. 

After  a  certain  length  of  time  the  fluid  constituents  of  the  milk  may 
become  partly  absorbed,  leaving  a  thick,  creamy,  semisolid  mass, 
resembling  tuberculous  pus.  The  condition  is  an  exceedingly  rare  one 
and  occasionally  is  mistaken  for  new  growth.  As  a  rule,  the  disease 
gives  rise  to  no  painful  symptoms,  and  its  presence  is  discovered  by 
accident. 

Treatment. — The  treatment  should  consist  in  evacuation  of  the 
cyst  by  incision  or  trocar,  and  the  application  of  pure  carbolic  acid  to 
its  walls;  or  by  complete  removal. 

Syphilitic  Lesions  of  the  Breast. — An  initial  lesion  may  occur  on  the 
nipple  of  a  woman  nursing  a  syphilitic  child  not  her  own.  As  in 
other  situations,  the  disease  appears  as  an  indolent  indurated  ulcer 
with  marked  axillary  gland  enlargement.  Mucous  patches,  mucous 
tubercles,  and  condylomata  may  also  occur  in  the  secondary  stage 
of  the  disease,  about  the  nipple  or  the  areola,  and  upon  the  raw  surfaces 
of  pendulous  breasts.  Gummata  are  comparatively  rare.  When  they 
occur  in  the  gland  tissue  they  must  be  distinguished  from  new  growths. 
This  generally  is  easy  by  recognizing  the  peculiar  elastic  consistence 
of  the  tumor,  by  the  history  and  presence  of  other  evidences  of  the 


4s.; 


DISEASES  OF  THE  MAMMARY  GLAND 


disease,  by  the  Wassermann  reaction  and  by  its  rapid  disappearance 
under  appropriate  treatment. 

Tuberculosis  of  the  Breast. — Tuberculosis  of  the  breast  may  occur 
as  a  cutaneous  lesion — lupus— which  has  already  been  described,  or 
as  a  localized  or  diffuse  tuberculous  inflammation  of  the  gland.  In 
the  localized  form  there  may  be  a  single  slow-growing  hard  tumor 
with  enlargement  of  the  axillary  lymph  nodes.  The  tumor  is  not 
sharply  circumscribed  and  the  disease  may  be  mistaken  for  carcinoma. 
The  tumor  is  made  up  of  a  mass  of  indurated  inflammatory  tissue,  in 
the  centre  of  which  is  a  softened  area  containing  caseous  material  or 


Fig.  258. — Tuberculosis  of  the  breast. 


pus.  Enlarged  lymph  channels  may  be  traced  from  the  tumor  to  the 
axillary  nodes,  many  of  which  may  be  enlarged  and  cheesy.  In  the 
diffuse  form  of  the  disease,  which  is  usually  secondary  to  tuberculosis 
elsewhere,  the  entire  gland  may  be  filled  with  caseating  nodules,  which 
later  break  down  and  discharge  upon  the  surface,  leaving  sinuses  and 
the  characteristic  cutaneous  lesions  (Fig.  259).  Bloodgood's  statement, 
that  all  abscesses  occurring  spontaneously  in  the  non-lactating  fe- 
male breast  are  tuberculous  in  character,  is  generally  borne  out  by 
experience. 

Treatment. — The  treatment  of  tuberculous  lesions  of  the  breast  is 
by  complete  excision  of  the  diseased  area,  with  the  lymph  channels 
and  nodes.    This  often  demands  amputation  of  the  gland  and  careful 


DISEASES  OF  THE  MAMMARY  GLAND 


487 


dissection  of  the  axilla.     Incision,  with  curetting,  and  packing  with 
iodoform  gauze,  has  been  recommended,  but  is  uncertain  in  its  results. 


\ 


Flo.  259. — Paget's  disease  of  the  breast. 

Paget's  Disease  of  the  Nipple. — Paget's  disease  is  an  obstinate 
form  of  dermatitis  of  the  nipple  and  areola,  occurring  generally  in 
women  about  the  menopause, 
and  is  followed  by  epithelioma 
and  duct  cancer.  The  disease  is 
rare.  It  is  characterized  by  a 
superficial  area  of  erosion  of  the 
skin,  which  is  red  and  tender. 
It  begins  on  the  nipple  or  the 
areola,  and  may  extend  for  a 
variable  distance  in  the  skin 
covering  the  gland.  It  re- 
sembles eczema  in  appearance. 
There  is  a  small  amount  of  se- 
cretion, which  dries  and  forms 
scabs  or  crusts.  There  is  often 
a  burning  or  itching  sensation. 
It  differs  from  simple  eczema  in 
that  its  borders  are  more  sharply 
defined  and  often  slightly  raised, 
and  is  not  relieved  by  usual 
methods  of  treating  eczema. 

The  treatment  of  this  con- 
dition when  the  diagnosis  is 
established  should  be  complete 
removal  of  the  gland. 

Diffuse  Virginal  Hypertrophy  of  the  Breast. — A  rare  condition  occur- 
ring at  or  near  puberty,  characterized  by  a  bilateral  hypertrophy 


Fig.  260. 


-Diffuse  virginal  hypertrophy  of 
breast. 


488 


DISEASES  OF  THE  MAMMARY  GLAND 


of  the  breast  tissue.  In  the  majority  of  instances  the  increase  in  size 
is  due  almost  wholly  to  an  overgrowth  of  the  fibrous  elements  of  the 
breast,  although  later  in  life  these  breasts  show  a  certain  amount  of 
glandular  hyperplasia.  The  abnormal  growth  is  gradual  and,  as  a 
rule,  is  unaccompanied  by  pain  or  discomfort  other  than  an  increased 
sense  of  weight.  The  breasts  may  grow  to  an  enormous  size  and 
give  rise  to  great  deformity  (Fig.  2G1). 

Treatment. — The  treatment  in  the  early  stage  should  consist  in 
support  by  bandages;  when  the  disease  has  progressed  to  the  stage 
of   discomfort,   partial   or   complete   amputation   is   to   be    advised. 


Fig.  261. — Chronic  cystic  mastitis. 

Senile  Parenchymatous  Hypertrophy. — This  condition  has  been 
extensively  studied  by  Koenig,  Reclus,  Schimmelbusch,  Warren,  and 
Bloodgood,  and  many  different  ideas  regarding  its  pathology  have 
been  expressed.  It  has  been  thought  to  be  a  chronic  inflammation, 
a  new  growth,  and  a  degenerative  change;  hence  the  terms  chronic 
cystic  mastitis,  cyst-adenoma  of  the  breast,  and  abnormal  involution  have 
been  applied  to  it  by  different  observers.  Next  to  carcinoma  it  is  the 
most  frequent  pathological  condition  found  in  the  female  breast  after 
thirty-five. 

It  occurs  generally  at  or  near  the  menopause,  and  is  characterized 
by  an  overgrowth  of  connective  tissue  and  the  formation  of  innum- 
erable large  and  small  cysts.  It  may  involve  only  a  part  of  one  breast 
or  the  greater  portion  of  both  glands. 

Two  types  are  recognized,  one  in  which  the  cysts  are  thin  walled 
and  contain  turbid  or  brownish  fluid,  the  other  in  which  many  of  the 


TUMORS  OF  THE  BREAST  489 

alveolar  spaces  and  cysts  are  filled  with  an  overgrowth  of  epithelium, 
forming  adenomatous  masses.  Both  varieties  are  prone  to  undergo 
carcinomatous  degeneration,  but  this  tendency  is  much  more  marked 
in  the  adenomatous  type. 

Symptoms. — The  symptoms  of  this  disease  arc  those  of  a  slowly 
developing,  irregular  mass  in  the  substance  of  the  breast  without 
pain,  retraction  of  the  nipple,  adhesion  to  the  muscle  or  skin,  and  with- 
out involvement  of  the  axillary  nodes.  To  the  examining  hand  the 
mass  often  resembles  carcinoma,  in  that  it  is  diffuse  and  fades  away 
gradually  into  the  surrounding  tissues.  Occasionally  fluctuation 
can  be  detected  if  a  large  cyst  is  present  near  the  surface.  Not  in- 
frequently two  or  more  masses  may  be  detected  in  the  same  breast, 
and  bilateral  involvement  is  not  uncommon.  The  tendency  of  this 
disease  to  undergo  malignant  change  renders  treatment  by  removal 
of  the  entire  gland  imperative. 


TUMORS  OF  THE  BREAST. 

The  female  breast  is  frequently  the  seat  of  tumor.  It  has  been 
estimated  that  one-fifth  of  all  tumors,  both  innocent  and  malignant, 
occur  in  the  breast.  While  innocent  tumors  occur  with  a  fair  degree 
of  frequency  in  the  breast,  the  number  of  malignant  growths  in  this 
gland  is  so  great  that  the  proportion  of  the  latter  is  three  to  one  of  the 
former.  As  a  general  rule,  it  may  be  stated  that  the  innocent  tumors 
develop  early  in  life,  the  malignant  at  a  later  period;  to  this,  however, 
there  are  many  exceptions,  as  cancer  has  frequently  been  observed 
between  the  ages  of  twenty  and  thirty,  and  sarcoma  and  adenoma  may 
occur  at  any  age.  It  must  also  be  remembered  that  many  of  the 
so-called  innocent  neoplasms  have  a  potential  malignancy,  in  that  they 
not  infrequently  develop  malignant  characteristics  if  allowed  to  remain 
in  the  breast  until  middle  life  or  old  age. 

Tumors  of  the  breast  may  be  divided  into  three  chief  groups,  the 
fibro-adenomata,  the  sarcomata,  and  the  cardnomata.  Other  varieties 
are  exceedingly  rare.  Lipomata,  angiomata,  endotheliomata,  chon- 
dromata,  lymphatic,  and  hydatid  cysts  have  been  reported. 

Fibro-adenoma. — Adenoma  is  a  tumor  composed  of  a  mass  of 
of  glandular  tissue  surrounded  by  a  fibrous  capsule.  Adenomata 
may  rarely  occur  as  single  or  multiple  tumors  in  one  or  both  breasts. 
They  are  rounded  in  shape,  hard  and  elastic  to  the  touch,  are  freely 
movable,  do  not  become  adherent  to  the  skin  or  muscle,  are  not 
accompanied  by  enlargement  of  the  axillary  lymph  nodes,  and  show 
no  tendency  to  recur  after  complete  removal.  These  tumors  vary  in 
size  from  that  of  a  hazelnut  to  that  of  an  orange,  or  even  larger.  They 
occur  in  the  majority  of  instances  during  the  menstrual  life  of  the 
individual.  They  are  rare  after  fifty,  and  have  not  been  reported 
before  the  thirteenth  year  of  life.    In  the  great  majority  of  adenomata 


490 


DISEASES  OF  THE  MAMMARY  GLAND 


there  is  an  overgrowth  of  connective  tissue,  and  to  these  tumors 
the  term  fibro-adenoma  has  been  applied  (Figs.  262).  When  the 
epithelial  elements  are  active,  fluid  may  be  secreted  in  one  or  more 
of  the  glandular  acini  and  cysts  are  formed.  To  describe  this  variety 
the  term  cyst-adenoma  or  adenocele  has  been  employed.  In  other 
instances  the  tumor  is  made  up  almost  entirely  of  myxomatous  fibrous 
tissue  which  surrounds  the  ducts  and  acini,  and  masses  of  this  tissue 
may  project  into  the  ducts,  giving  rise  to  the  term  intracanaUcular 
myxoma.  Occasionally  one  portion  of  a  tumor  may  be  distinctly 
fibrous  and  another  glandular  and  cystic.  These  tumors  are  often 
spoken  of  as  fibrocyst-adenomata.  Small  tumors  occasionally  develop 
in  the  walls  of  the  ducts,  project  into  the  lumen,  and  give  rise  to  a 


Fig.  262. — Fibro-adenoma  of  female  breast. 


collection  of  fluid,  causing  a  fusiform  dilatation.  Often  they  have  a 
papillomatous  appearance,  and  are  spoken  of  as  intracanalieidar 
adenoyaj)  Mom  a  ta . 

These  tumors,  as  a  rule,  produce  no  symptoms;  they  are  generally 
discovered  by  accident  and  their  growth  is  exceedingly  slow.  There  is 
positive  evidence  to  show  that  in  certain  rare  cases  these  tumors, 
after  remaining  for  a  long  period  of  time  as  stationary  or  slowly 
developing  innocent  growths,  may  suddenly  change  their  character, 
grow  rapidly,  and  become  converted  into  malignant  neoplasms. 
Three  such  examples  came  under  the  author's  observation  in  one  year. 

Diagnosis.— Fibro-adenomatous  tumors  are  to  be  distinguished 
from  carcinomata  by  the  fact  that  they  are  of  slow  growth,  are  dis- 
tinctly circumscribed,  are  freely  movable,  and  not  adherent  to  the 
skin  or  muscle,  are  not  accompanied  by  retraction  of  the  nipple  or 


TUMORS  OF  THE  BREAST  491 

axillary  involvement;  from  the  sarcomata,  by  their  slow  growth  and 
comparatively  small  size,  and  by  the  fact  that  they  are  frequently 
multiple;  from  chronic  mastitis,  by  their  round  shape,  their  distinctly 
circumscribed  borders,  and  by  evidences  of  encapsulation. 

Treatment.-  On  account  of  the  possibility  of  these  tumors  becoming 
converted  into  malignant  growths,  their  removal  should  be  advised 
in  all  cases.  As  a  rule,  this  is  accomplished  best  by  an  incision  radiating 
from  the  nipple  or  around  the  periphery  of  the  gland.  In  the  majority 
of  cases,  especially  when  the  tumor  is  located  near  the  periphery,  the 
latter  method  should  be  employed.  By  making  a  curved  incision 
around  the  outer,  or  outer  and  inferior  border  of  the  gland,  the  breast 
may  be  turned  upward  and  the  growth  approached  from  its  under 
surface.  The  tumo'r  when  exposed  is  easily  enucleated.  In  certain 
cases  when  multiple  tumors  exist  or  when  there  is  extensive  cystic 
disease  removal  of  the  entire  gland  is  advisable. 

Sarcoma. — Sarcoma  is  a  comparatively  rare  disease  of  the  breast. 
It  occurs  in  twro  forms,  the  round-cell,  rapidly  growing  variety,  which 
later  infiltrates  the  breast  tissue;  and  the  type  which  not  infrequently 
develops  on  a  pre-existing  intracanalicular  myxoma.  The  former  is 
exceedingly  malignant,  occasionally  involves  the  axillary  lymph  node, 
and  is  disseminated  by  the  blood  current;  the  latter  is  less  malignant, 
is  often  cured  by  early  and  complete  removal. 

Diffuse  sarcoma  arises  from  the  connective  tissue  of  the  gland,  and 
its  growth  often  includes  portions  of  the  glandular  substance,  which 
may  later  develop  into  cysts,  forming  the  type  known  as  cystosarcoma. 
Secondary  myxomatous  changes  may  rarely  occur  and  when  this 
occurs  the  tumor  is  spoken  of  as  a  myxosarcoma.  Cartilage  is  occasion- 
ally found  in  these  growths,  as  in  those  of  the  parotid  gland,  giving 
rise  to  the  term  chondrosarcoma.  In  the  encapsulated  less  malignant 
type,  which  comprises  about  80  per  cent,  of  all  breast  sarcomata,  the 
disease  may  exist  for  years  as  a  benign  growth;  it  then  increases 
rapidly  in  size,  apparently  breaks  through  its  capsule,  and  invades  the 
tissues  of  the  gland.  This  change  often  is  evidenced  by  a  bluish 
discoloration  of  the  skin,  which  later  ulcerates  and  develops  into  a 
fungating  mass. 

Breast  sarcoma  occurs,  as  a  rule,  in  individuals  under  fifty  years 
of  age.  Its  growth  is,  in  the  early  stages,  painless,  but  in  the  case  of 
the  round-cell  variety  exceedingly  rapid.  Nursing  seems  to  exert 
a  stimulating  influence  upon  the  growth  of  breast  sarcomata,  as  they 
progress  with  great  rapidity  during  lactation. 

Diagnosis. — The  diagnosis  of  sarcoma  of  the  breast  is  by  no  means 
always  an  easy  matter,  and  in  certain  cases  impossible  before  a  micro- 
scopic examination  is  made  of  the  tissue.  The  chief  clinical  points 
are  its  rapid  growth,  the  age  of  the  patient,  and  the  late  involvement 
of  the  lymph  nodes.  The  encapsulated  myxo-sarcomata  resemble 
at  first  the  fibro-adenomata  in  being  sharply  circumscribed  tumors, 
and  occasionally  cystic;  they  differ,  however,  in  that  they  grow  much 


492  DISEASES  OF  THE  MAMMARY  GLAND 

faster,  attain  a  large  size,  and  are  always  single.  The  round-cell 
infiltrating  sarcomata  may  closely  resemble  the  rapid  and  cellular 
carcinomata  (Plate  XVII).     Absence  of  enlargement   of  the  lymph 

nodes  would  favor  the  diagnosis  of  sarcoma;  if  these  an-  involved, 
the  diagnosis  must  rest  in  doubt  until  the  ti>>ne  can  he  examined 
microscopically. 

Treatment. — Early  and  complete  removal  is  the  only  rational 
treatment  of  this  disease.  In  the  slowly  growing  myxosarcomata 
the  entire  breast  and  axillary  glands  should  be  removed;  in  the 
nmre  rapidly  growing  diffuse  sarcomata  the  complete  Halsted  operation 
should  be  performed.  These  measures,  if  carried  out  at  an  early 
period  of  the  disease,  often  will  bring  about  a  radical  cure;  and  it 
should  be  remembered,  moreover,  that  a  local  return  of  the  growth 
often  may  be  successfully  treated  by  surgical  means  even  after  three 
or  four  recurrences.  In  the  rapidly  growing  round-cell  variety  the 
progno-i-  i-  always  grave,  as  dissemination  of  the  disease  by  the 
blood  current  occurs  at  an  early  period,  and  operation-^  which  are 
at  all  delayed  are  apt  to  give  but  temporary  relief. 

In  inoperable  sarcomata  of  the  breast  and  in  extensive  recurrences 
the  x-rays  offer  a  chance  of  improvement,  arrest  of  the  growth,  or 
radical  cure.  The  use  of  erysipelas  toxin  in  these  cases  has  been 
followed  by  success  in  a  few  instances. 

Carcinoma. — Carcinoma  is  by  far  the  commonest  disease  of  the 
female  breast.  It  is  more  frequently  encountered  than  sarcoma, 
the  proportion  being  about  12  to  1.  If  we  exclude  the  uterus,  certainly 
no  organ  in  the  female  body  is  as  frequently  the  seat  of  cancerous 
disease  a-  the  breast.  The  disease  may  rarely  occur  in  the  male 
breast.  Regarding  the  age  at  which  it  develops,  it  may  be  stated  in 
general  that  it  is  a  di-ea>e  of  late  middle  life,  the  greatest  number  of 
cases  occurring  in  individuals  between  forty  and  fifty  years  of  age. 
It,  however,  may  occur  at  any  earlier  period,  and  several  instances 
are  on  record  of  the  disease  in  women  between  fifteen  and  thirty. 
The  influence  of  the  married  state,  pregnancy,  and  lactation  is  ap- 
parently unimportant  in  the  etiology  of  cancer,  but  carcinoma  occur- 
ring in  a  breast  during  pregnancy  invariably  assumes  an  extremely 
malignant  type.  Heredity  plays  a  certain  part  in  the  etiology,  and 
there  is  -ome  evidence  to  suggest  that  contagion  may  be  an  important 
factor.  The  history  of  a  blow  or  other  trauma  is  misleading,  as  few 
women  reach  the  cancer  age  without  suffering  such  injuries.  Irritation 
of  the  gland,  produced  by  the  presence  of  other  new  growths  or  of  a 
chronic  mastitis,  is  thought  by  many  observers  to  favor  development 
nf  this  disease. 

Carcinoma  of  the  breast  may  arise  from  the  glandular  elements 
or  from  the  milk  ducts.  The  former  is  called  acinous  cancer;  the 
latter,  duct  cancer.  Acinous  cancer,  which  is  by  far  the  commoner 
variety,  occurs  in  two  forms:  the  hard  fibrous  carcinoma  or  scirrhus, 
and  the  soft  cellular  variety  or  encephaloid  cancer. 


PLATE  XVII 


Ulcerating  Sarcoma  of  Breast. 


TUMORS  OF  THE  BREAST 


493 


Scirrhous  cancer  of  the  breast  is  the  commonest  form  of  the  disease. 
It  may  begin  in  any  part  of  the  gland,  but  is  more  frequently  seated 
near  the  nipple  or  in  the  upper  and  outer  quadrant.1  When  first 
noticed,  it  is  usually  an  oval,  deep-seated,  indurated  movable 
lump  of  stony  hardness.  It  is  not  sharply  circumscribed,  and  as  it 
develops  it  can  be  felt  to  grow  outward  into  the  surrounding  tissues, 
which  gradually  become  more  infiltrated  and  dense.  Adhesions 
soon  form  between  the  tumor  and  the  skin,  and  also  with  the  underlying 


Fit 


muscle.  The  nipple  is  frequently  retracted,  and  the  axillary  lymph 
nodes  become  enlarged.  The  latter  occurs  early  in  the  disease,  prob- 
ably about  the  second  month,  but  owing  to  the  location  of  the  glands 
and  the  surrounding  fatty  tissue,  they  are  rarely  recognized  until  a 


1  It  must  be  remembered  that  the  upper  angle  of  the  breast,  which  normally  extends 
toward  the  axilla  along  the  lower  border  of  the  pectoral  muscle,  is  occasionally  sur- 
mounted by_an  oval  mass  of  glandular  tissue,  or  such  a  mass  may  exist  without  direct 
glandular  connection  with  the  breast,  resembling  a  supernumerary  mamma,  in  which 
carcinoma  may  develop. 


494 


DISEASES  OF   THE  MAMMARY  GLAND 


later  period.  As  the  growth  of  the  tumor  advances  and  the  surrounding 
tissues  are  infiltrated,  an  atrophy  or  shrinkage  of  the  entire  gland  may 
occur  in  certain  cases,  from  contraction  of  the  fibrous  tissue,  giving  rise 
to  the  variety  sometimes  called  "withering  cancer"  (Fig.  263).  In  the 
majority  of  instances,  however,  the  growth  involves  a  large  part  of 
the  gland,  the  overlying  skin,  and  the  underlying  muscles  and  chest- 
wall.  If  allowed  to  progress,  the  subcutaneous  lymph  spaces  may 
become  infiltrated  with  the  disease,  which  results  in  a  hardening  of 
the  skin  with  the  formation  of  numerous  dense  white  nodules.  When 
this  extends  over  a  large  area  of  the  chest  wall,  respiration  may  be 
embarrassed,  and  the  condition  is  spoken  of  as  cancer  en  cuirasse. 


Fig.  264. — Ulcerating  carcinoma  of  breast. 


As  the  growth  progresses  the  lymphatics  of  the  axilla  and  supra- 
clavicular region  enlarge,  forming  later  massive  tumors  which  press 
upon  the  vessels  and  nerves  and  cause  edema  of  the  arm  and  neuralgia 
in  the  branches  of  the  brachial  plexus.  In  most  cancerous  growths  of 
the  breast  the  first  lymph  nodes  to  become  involved  are  those  lying 
along  the  inferior  border  of  the  great  pectoral  muscle.  Exceptionally, 
when  the  disease  first  attacks  the  upper  and  inner  quadrant,  the  medi- 
astinal nodes  are  primarily  affected,  chiefly  through  lymph  channels 
entering  the  thorax  through  the  second  intercostal  space.  Lymphatic 
edema  may  occur  from  obstruction  of  the  lymph  channels,  producing 
a  condition  of  the  skin  of  the  upper  extremity  and  shoulder  resembling 


PLATE  XVIII 


Ulcerating  Carcinoma  of  Breast. 
'Lumiere   Photograph.) 


TUMORS  OF  THE  BREAST  495 

elephantiasis,  which  often  renders  the  arm  practically  useless  from  its 
increased  weight. 

Encephaloid  cancer  presents  a  very  different  clinical  picture.  The 
growth  occurs  as  a  soft,  elastic,  rapidly  growing  tumor,  which  soon 
infiltrates  the  entire  tissue  of  the  breast  and  does  not  produce  retraction 
of  the  nipple.  The  disease  early  infects  the  lymphatics  and  infiltrates 
the  skin,  which  becomes  discolored  and  breaks  down,  leaving  a  foul, 
rapidly  f ungating  ulcer  (Fig.  2G4).  Rapid  dissemination  of  the  disease 
takes  place,  which  speedily  leads  to  a  fatal  termination. 

Duct  cancer  is  the  rarest  and  least  malignant  form  of  the  disease. 
It  occurs  as  a  small,  slowly  developing  papillomatous  tumor  growing 
from  the  walls  of  a  dilated  milk  duct,  usually  near  the  nipple.  It 
occurs  generally  about  the  menopause,  when  the  glandular  structure 
of  the  breast  atrophies  and  the  galactophorous  ducts  are  prone  to 
enlarge,  forming  a  general  cystic  condition  of  the  breast.  The  tumor 
is  softer  than  the  scirrhous  variety,  is  often  covered  by  a  bluish  or 
purplish  skin,  and  on  section  is  found  to  be  surrounded  by  a  capsule 
made  up  of  the  walls  of  the  dilated  duct. 

Symptoms. — The  early  growth  of  a  carcinoma  of  the  breast  is, 
as  a  rule,  unaccompanied  by  symptoms  of  any  kind.  Pain  is  rarely 
present  until  the  disease  has  extended  to  the  axillary  lymph  nodes 
and  produces  pressure  on  the  nerves.  In  the  earlier  stages  of  scirrhus 
and  encephaloid  a  sense  of  weight  in  the  breast  may  be  experienced 
by  the  patient;  and  in  neurotic  subjects,  shooting  pains,  burning 
sensations,  and  other  forms  of  paresthesia  may  be  present.  Genuine 
pain,  shooting  into  the  breast  and  down  the  arm,  is  a  fairly  constant 
late  symptom,  which  may  be  so  severe  as  to  cause  great  suffering  and 
to  necessitate  the  use  of  opiates.  The  presence  of  an  intermittent 
bloody  discharge  from  the  nipple  is  one  of  the  earliest  signs  of  duct 
cancer.  Loss  of  weight  and  strength,  anorexia,  anemia,  and  a  peculiar 
sallow,  unhealthy  appearance  of  the  skin  develop  late  in  the  disease, 
and  are  due  to  absorption  of  toxins  or  to  secondary  involvement  of 
other  organs.  As  this  cachexia  develops  the  patients  become  bed- 
ridden and  exhausted,  and  eventually  die  of  asthenia.  Metastasis  in 
cancer  of  the  breast  is  common.  It  occurs  most  frequently  in  the  liver, 
lungs,  pleura,  and  bones,  particularly  the  spine,  sternum,  femur,  and 
humerus.  More  rarely  metastases  occur  in  the  abdominal  organs, 
or  central  nervous  system.  Formerly  these  secondary  deposits  were 
thought  to  be  largely  due  to  transmission  of  cancer  cells  by  the  general 
circulation,  after  extension  of  the  disease  to  the  blood  from  the  axillary 
lymphatics.  Handley,  however,  has  recently  shown  that  extension 
of  the  disease  takes  place  to  a  larger  extent  by  direct  growth  of  columns 
of  cancer  cells,  along  the  deep  fascia  often  without  visible  involvement 
of  the  superficial  layers  of  the  skin,  and  that  these  prolongations  of  the 
disease  direct  from  the  parent  growth  may  reach  the  liver  by  means 
of  the  round  ligament;  the  humerus,  sternum,  clavicle,  spine,  and 
femur  at  points  where  the  deep  fascia  is  attached  to  these  structures. 


490  DISEASES  OF   THE   MAMMARY  GLAND 

It  is  a  significant  fact  that  these  metastatic  deposits  are  often  present 
without  the  occurrence  of  pulmonary  lesions,  which  would  be  difficult 
to  explain  if  the  old  theory  of  blood  dissemination  were  true. 

Diagnosis. — While  accurate  diagnosis  is  a  comparative  simple 
matter  late  in  the  disease  when  all  the  characteristic  symptoms 
and  signs  are  present,  in  the  earlier  stages,  when  treatment  offers  a 
chance  for  radical  cure,  the  diagnosis  is  often  attended  with  con- 
siderable difficulty.  The  presence  of  a  hard  tumor  in  the  breast 
of  a  women  over  thirty  should  always  be  regarded  with  suspicion. 
If  the  growth  progresses  rapidly,  is  single,  and  is  early  associated 
with  retraction  of  the  nipple,  enlargement  of  the  axillary  lymph 
nodes,  or  dimpling  of  the  skin  over  the  centre  of  the  mass,  the  prob- 
abilities are  that  it  is  carcinomatous  in  character.  If  in  addition  to 
this,  the  growth  infiltrates  the  gland  without  distinctly  circumscribed 
limits  and  the  overlying  integument  assumes  the  appearance  of  "pig 
skin,"  or  dense  lymphatic  infiltration,  the  diagnosis  is  certain.  In 
differentiating  between  an  early  cancerous  nodule  and  chronic  cystic 
mastitis,  the  fact  that  the  nodule  is  single  and  its  growth  pro- 
gressive would  favor  the  diagnosis  of  cancer;  the  absence  of  any 
sharp  line  of  demarcation  between  it  and  the  surrounding  breast- 
tissue  would  serve  to  distinguish  it  from  an  adenomatous  tumor. 
This  fact  would  also  enable  one  to  exclude  encapsulated  spindle-cell 
sarcoma,  while  the  comparatively  slow  growth  and  limited  extent  of  a 
beginning  scirrhous  carcinoma  would  distinguish  it  from  the  rapidly 
growing,  infiltrating,  round-cell  sarcoma.  There  are,  however,  no 
distinguishing  features  which  will  enable  one  to  differentiate  between 
an  encephaloid  carcinoma  and  a  round-cell  sarcoma,  unless  it  be  that 
the  growth  of  the  latter  is  more  rapid  and  unaccompanied  by  enlarged 
lymph  nodes. 

In  all  doubtful  cases  early  and  complete  removal  of  the  suspicious 
nodule  is  to  be  recommended.  This  should  always  be  effected  without 
cutting  into  the  diseased  mass.  Under  favorable  conditions  the 
tumor  may  be  immediately  examined  by  means  of  frozen  sections, 
and  if  its  malignancy  is  demonstrated  the  complete  operation  can  be 
performed  at  once.  When  frozen  section  examination  by  a  competent 
pathologist  is  not  possible,  the  safest  course  to  pursue  in  all  growths 
of  doubtful  character  is  by  radical  operation. 

Prognosis. — In  general  it  may  be  stated  that  the  disease  if  un- 
treated always  leads  to  a  fatal  termination.  The  more  cellular  the 
growth  the  more  rapid  its  course.  In  cases  of  "withering  cancer" 
or  the  exceedingly  slow-growing  duct  cancers  the  progress  may  lie 
so  delayed  that  death  not  infrequently  takes  place  from  other 
causes.  The  average  duration  of  life  in  an  untreated  case  of  encepha- 
loid carcinoma  of  the  breast  is  from  nine  to  eighteen  months;  in 
ordinary  scirrhus,  from  two  to  three  years.  The  prognosis  in  cancer  of 
the  breast  treated  by  modern  operative  measures  has  steadily  improved 
during  the  past  twenty  years.     In  general,  it  may  be  stated  that 


TUMORS  OF  THE  BREAST  197 

the  operative  mortality  should  not  be  over  3  per  cent.,  and  the  three- 
year  cures  should  be  upward  of  30  per  cent.  In  selected  early  cases, 
where  the  growth  is  small  and  no  enlarged  lymph  nodes  can  be  felt 
in  the  axilla,  the  percentage  of  cures  is  between  60  and  70. 

Treatment.— As  soon  as  the  diagnosis  of  carcinoma  of  the  breast 
is  established,  complete  removal  of  the  disease  should  be  under- 
taken at  the  earliest  possible  moment.  While  some  surgeons  still 
advise  simple  removal  of  the  gland  and  the  axillary  contents  in  cases 
of  early  fibrous  carcinoma,  statistics  prove  that  the  general  employ- 
ment in  these  cases  of  the  complete  Halsted  operation  is  followed  by 
a  larger  percentage  of  cures  than  when  any  other  method  is  adopted. 
This  method  is  applicable  to  all  cases  of  carcinoma  of  the  breast  when 
the  disease  appears  Jimited  to  the  mammary  gland  and  the  axillary 
lymph  nodes.  If  the  growth  is  small  and  the  lymph  nodes  but  little 
if  any  enlarged,  removal  of  the  breast,  the  pectoral  muscles,  and  the 
areolar  tissue  of  the  axilla  will  be  sufficient.  If,  however,  the  axillary 
nodes  are  extensively  involved,  and  especially  if  the  lymphatics  high 
up  in  the  axilla  under  the  tendon  of  the  pectoralis  minor  muscle  are 
diseased,  the  supraclavicular  space  must  be  exposed  and  cleared  of 
its  lymphatics  and  areolar  tissue.  If  the  disease  has  involved  the 
chest  wall,  the  great  vesssels  of  the  axilla,  and  large  areas  of  the 
skin  (cancer  en  cuirasse),  or  if  the  supraclavicular  lymph  nodes  can 
be  felt,  the  operation  should  not  be  undertaken  with  a  view  to  radical 
cure  of  the  disease,  although  in  certain  cases  this  or  less  extensive 
operations  are  justifiable  as  palliative  measures.  In  a  recent  publica- 
tion Barker  states  that  "the  more  localized  the  primary  focus  of 
carcinoma  in  the  breast  is,  the  more  wide-reaching  should  be  the 
excision;  that  is  to  say,  there  is  in  such  cases  a  fair  prospect  of  complete 
eradication  of  the  disease  by  a  wide-reaching  operation.  The  converse 
rule  appears  also  to  have  much  to  recommend  it,  viz.,  that  the  more 
wide-reaching  the  disease,  the  more  clearly  should  the  operator  keep 
palliation  in  view,  and  by  limiting  his  operation  avoid  the  risk  of 
extreme  shock." 

The  operation  for  complete  removal  of  the  female  breast  is  carried 
out  as  follows:  The  axilla  should  be  shaved  and  the  entire  region 
of  the  neck,  shoulder,  upper  arm,  breast,  and  side  wall  of  the  chest 
should  be  prepared  in  the  usual  manner.  After  the  patient  is  anes- 
thetized the  arm  of  the  affected  side  should  be  held  at  a  right  angle 
with  the  body,  and  an  incision  made  from  the  humeral  insertion 
of  the  pectoralis  major  tendon  over  the  point  of  the  shoulder  and  then 
downward  on  the  chest  wall  to  the  inner  side  of  the  nipple  to  a  point 
two  or  three  inches  below  the  lower  margin  of  the  gland;  from  the 
upper  portion  of  this  cut  another  incision  is  carried  downward  along 
the  edge  of  the  pectoral  muscle  and  then  curving  inward  to  meet  the 
lower  extremity  of  the  first  incision;  or  if  the  disease  is  more  extensive 
and  it  is  desirable  to  remove  a  larger  area  of  skin,  the  incision  is  modified 
as  seen  in  Fig.  265.  This  incision  is  carried  through  the  skin  and 
32 


498 


DISEASES  OF   THE   MAMMARY  GLAND 


superficial  fascia,  which  are  dissected  free  on  either  side  to  the  muscular 
layer,  exposing  the  pectoral  muscle  throughout  over  its  entire  length. 
The  tendon  of  the  muscle  is  next  separated  from  its  attachment 


M 


Mm  m?>> 


mBSSmBHm 


/    i 


I     I 


Fig.  265. — Halsted's  breast  operation,  skin  incision. 

to  the  humerus  and  retracted  downward  (the  clavicular  fibres  may  be 
left),  and  the  attachment  of  the  pectoralis  minor  muscle  exposed  and 
severed  (Fig.  26(3).    The  axillary  space  thus  exposed  is  cleaned  from 


Fig.  266. — Halsted's  breast  operation,  later  stage. 

above  downward  of  all  fascia,  lymphatics,  and  areolar  tissue,  care 
being  taken  when  the  lower  limit  is  reached  to  preserve  if  possible 
the  subscapular  and  posterior  thoracic  nerves.     When  the  axillary 


TUMORS  OF  THE  BREAST  499 

space  is  thoroughly  cleared,  the  costal  and  sternal  attachments  of 
the  pectoralis  major  muscle  are  divided,  as  well  as  those  of  the 
pectoralis  minor,  and  the  entire  mass,  consisting  of  the  breast,  both 
muscles,  and  the  axillary  glands  and  areolar  tissue,  is  removed.  If 
the  supraclavicular  space  is  to  be  explored,  a  curved  or  straight  in- 
cision is  made  above  the  clavicle,  and  the  lymphatic  structure  and 
areolar  tissue  removed  along  the  subclavian  vessels  and  for  a  distance 
of  two  or  more  inches  above  the  clavicle  behind  the  sternomastoid 
muscle.  When  this  is  accomplished,  the  wounds  are  closed  as  com- 
pletely as  possible  with  silk  or  silkworm-gut  sutures,  and  the  remain- 
ing uncovered  portion  immediately  covered  with  Thiersch  skin-grafts 
taken  from  the  thigh  or  arm.  A  small  opening  for  drainage  should  be 
cut  through  the  axillary  flap  and  a  small  cigarette  drain  introduced, 
after  which  a  large  gauze  and  cotton  dressing  should  be  applied  and 
the  arm  fixed  at  a  right  angle  across  the  chest,  and  the  whole  held 
by  a  large  many-tailed  bandage. 

As  a  rule,  there  is  little  reaction  after  the  operation  if  care  is  taken 
to  avoid  hemorrhage  and  infection.  Often  the  patients  are  allowed  to 
sit  up  on  the  fifth  or  sixth  day.  If  the  temperature  remains  normal, 
the  dressing  need  not  be  removed  for  ten  days. 

In  inoperable  carcinoma  and  in  extensive  local  recurrences  of  the 
disease,  the  use  of  the  .r-rays,  and  especially  the  improved  therapeutic 
rays  generated  by  the  new  Coolidge  tube,  may  be  employed.  The 
marked  improvement  following  this  treatment,  in  seemingly  hopeless 
cases,  has  led  the  author  to  advise  a  series  of  treatments  by  this  method 
as  a  prophylactic  measure  immediately  after  recovery  from  a  radical 
operation,  in  all  cases  of  breast  cancer. 


CHAPTER  XX. 
INJURIES  OF  THE  ABDOMEN. 

Contusions. — Contusions  of  the  abdominal  wall  are  of  frequent 
occurrence,  resulting  from  all  manner  of  traumata.  They  vary  in 
their  results  from  a  slight  feeling  of  soreness  and  general  discomfort 
to  a  rapidly  fatal  collapse.  This  difference,  which  is  observed  not 
infrequently  in  injuries  quite  similar  in  their  method  of  production, 
in  the  amount  of  force  expended,  and  in  their  outward  signs,  is  due 
to  the  presence  or  absence  of  associated  internal  or  visceral  injury. 

The  effects  of  a  blow  on  the  anterior  abdominal  wall  are  modified 
by  the  condition  of  the  abdominal  muscles.  An  unexpected  blow  on 
the  pit  of  the  stomach  received  while  the  muscles  are  in  a  state  of 
comparative  relaxation  is  often  followed  by  severe  shock,  nausea, 
and  temporary  muscular  weakness,  due,  as  Crile  has  shown,  to  the 
concussion  being  transmitted  to  the  pericardial  portion  of  the  dia- 
phragm. If,  however,  the  blow  is  expected  and  the  abdominal  muscles 
are  rigidly  set,  little  or  no  inconvenience  is  produced.  The  same  is 
true  of  other  parts  of  the  abdomen;  an  expected  blow  or  contusion 
produces,  as  a  rule,  less  visceral  injury  than  one  received  while  the 
abdominal  wall  is  relaxed.  A  blow  directly  over  a  distended  hollow 
viscns,  as  the  stomach,  intestine,  or  urinary  bladder,  may  cause  a 
rupture  and  extravasation  of  the  contained  matter,  while  a  like  blow 
received  when  the  organ  is  in  a  state  of  collapse  may  produce  no 
untoward  effect.  Enlargements  of  the  liver  and  spleen  to  such  an 
extent  that  they  lie  below  the  protecting  arches  of  the  ribs,  favor  their 
injury  as  a  result  of  abdominal  trauma.  It  must  be  remembered 
that  extensive  and  fatal  visceral  ruptures  may  be  produced  by  com- 
paratively slight  contusions;  that  the  amount  of  internal  injury  is 
due  more  to  the  condition  of  the  organ  and  the  protecting  abdominal 
muscles  than  to  the  force  of  the  blow. 

The  extraperitoneal  results  of  abdominal  contusions  are:  bruises 
of  the  skin;  subcutaneous  ecchymoses;  hematomata  beneath  the 
skin,  between  the  muscular  layers,  or  between  the  muscles  and  the 
peritoneum;  rupture  of  the  muscles  at  their  points  of  attachment 
or  in  the  intervening  portions;  contusion  or  rupture  of  the  kidney. 
The  intraperitoneal  injuries  may  be:  contusion  and  rupture  of  the 
parietal  peritoneum;  contusion  or  rupture  of  the  stomach  or  intestine; 
contusion  or  rupture  of  the  liver,  spleen,  or  pancreas;  and  injury  to 
the  omentum  or  mesentery.  Ruptures  of  the  bladder  may  or  may 
not  involve  the  peritoneal  cavity.     In  rupture  of  any  portion  of  the 


CONTUSIONS  501 

alimentary  canal,  extravasation  of  the  contained  matter  will  result, 
producing  immediate  peritoneal  irritation,  as  evidenced  by  pain, 
tenderness,  thoracic  respiration,  retracted  abdomen  and  muscular 
rigidity,  and  later  will  be  followed  by  septic  peritonitis. 

In  regard  to  the  varying  degrees  of  peritoneal  irritation  produced 
by  the  extravasation  of  material  from  upper  or  lower  portions  of  the 
alimentary  canal,  it  may  be  stated  that  the  intensely  acid  gastric 
juice,  and  the  pancreatic  secretion  produce  a  greater  degree  of  peri- 
toneal irritation  than  the  contents  of  the  lower  bowel.  This  is  evi- 
denced by  a  more  acute  initial  pain,  and  a  higher  degree  of  muscular 
spasm.  Injuries  of  the  liver  or  spleen  following  abdominal  contusions 
are  generally  found  to  be  more  or  less  extensive  fractures,  which 
result  in  extravasati'on  of  blood,  which  varies  in  amount  with  the 
extent  of  the  injury.  Such  hemorrhages  are  indicated  by  a  condition 
of  shock  and  by  more  or  less  localized  peritoneal  irritation. 

In  the  rare  ruptures  of  the  pancreas  from  abdominal  contusion, 
the  sudden  occurrence  of  glycosuria  is  strongly  suggestive.  Injuries 
of  the  omentum  and  mesentery  are  rarely  found  unassociated  writh 
visceral  injury.  If  their  larger  vessels  are  wounded,  extensive  hemor- 
rhage will  result.  A  distended  bladder  may  be  ruptured  by  a  blow 
over  the  hypogastrium,  but  the  injury  is  associated  more  often  with 
fracture  of  the  pelvis. 

Diagnosis. — Contusions  of  the  abdomen  are  apt  to  be  associated 
with  a  condition  of  early  and  transitory  shock  which  does  not  nec- 
essarily point  to  visceral  injury.  If  the  results  of  the  injury  are 
limited  to  the  abdominal  wall,  the  symptoms  wrill  be  those  of  con- 
tusion and  laceration  of  other  muscular  structures,  which  are  sore- 
ness, pain  on  motion,  and  tenderness  to  pressure.  If  an  hematoma 
forms,  it  will  be  indicated  by  the  presence  of  a  more  or  less  circum- 
scribed tumor,  which,  if  superficial,  will  fluctuate,  and  if  situated 
deeply  beneath  the  thick  muscular  layers,  may  simply  impart  to  the 
examining  hand  a  sensation  of  elasticity.  Occasionally  an  extensive 
retroperitoneal  hemorrhage  in  the  flank  may  be  felt  from  in  front 
as  a  deep-seated  abdominal  tumor. 

If,  following  an  abdominal  contusion  with  or  without  signs  of 
superficial  injury,  there  is  progressively  increasing  shock,  indicated 
by  pallor,  nausea,  cold  extremities,  and  a  weak  pulse  increasing  in 
rapidity,  with  localized  or  general  abdominal  pain  and  an  appre- 
ciable rigidity  of  the  muscles  which  is  not  accounted  for  by  local 
injury,  the  case  is  in  all  probability  one  of  visceral  injury.  If,  in 
addition  to  the  above  symptoms,  there  is  evidence  of  free  fluid  in 
the  peritoneal  cavity,  indicated  by  dulness  or  flatness  in  the  flanks, 
which  disappears  on  turning  the  patient  on  the  opposite  side,  or 
if  free  gas  is  present  in  the  peritoneal  cavity,  evidenced  by  oblit- 
eration of  the  liver  dulness,  and  if  the  first  depression  is  followed 
by  gradual  rise  in  temperature,  with  an  increasing  pulse  rate,  the 
diagnosis  is  rendered  still  more  probable.     If  these  symptoms  are 


502  INJURIES  OF   THE  ABDOMEN 

all  progressive  and  the  patient  passes  rapidly  into  a  state  of  profound 
collapse,  the  diagnosis  is  certain. 

Severe  localized  pain  with  marked  rigidity  over  the  epigastrium 
points  to  a  rupture  of  the  stomach  or  injury  to  the  pancreas;  pain 
and  tenderness  limited  to  the  right  hypochondrium  with  evidences  of 
free  fluid  suggests  a  rupture  of  the  liver;  the  same  on  the  left  side 
suggests  a  rupture  of  the  spleen;  pain  and  rigidity  about  the  umbilicus 
or  in  the  lower  part  of  the  abdomen,  without  other  symptoms,  suggest 
rupture  of  the  intestine;  pain  in  the  hypogastrium,  with  tenesmus 
and  the  passage  of  bloody  urine  or  an  empty  bladder,  indicates  rupture 
of  that  organ;  while  pain  in  the  flank,  with  hematuria  and  a  retro- 
peritoneal exudate,  suggests  contusion  or  rupture  of  the  kidney. 

In  cases  of  visceral  injury  the  symptoms  and  signs  are  rarely  so 
localized  a-  to  warrant  a  positive  diagnosis  as  to  the  nature  of  the 
lesion,  and  in  many  cases  the  symptoms  are  so  mild,  obscure,  or 
misleading  that  the  presence  or  absence  of  such  lesions  may  only 
be  surmised.  In  all  cases  of  doubt  the  indications  are  for  an  immediate 
laparotomy  for  purposes  of  exact  diagnosis  and  treatment,  as  the 
symptoms  and  signs  in  many  cases  give  no  indication  of  the  extent 
and  gravity  of  the  lesion.1 

Treatment. — The  treatment  of  simple  contusions  of  the  abdominal 
wall  consists  in  rest  and  the  application  of  hot  stupes  or  other  soothing 
measures.  If  an  hematoma  develops  beneath  the  skin  or  between 
the  muscles,  the  rest  should  be  continued  until  the  fluid  is  absorbed. 
In  large  hematomata  aseptic  aspiration  of  the  fluid  with  subsequent 
compression  will  often  materially  shorten  the  duration  of  treatment. 
If  there  is  evidence  of  continued  extravasation  of  blood,  which  is  not 
controlled  by  pressure,  the  part  should  be  exposed  by  incision,  the 
bleeding  vessel  ligated,  or  the  hemorrhage  arrested  by  gauze  packing. 
Hematomata  in  the  flank  associated  with  rupture  of  the  kidney, 
frequently  become  infected,  giving  rise  to  extensive  suppuration,  which 
-hould  be  treated  by  incision  and  drainage. 

In  the 'presence  of  symptoms  indicating  visceral  injury  or  severe 
intra-abdominal  hemorrhage,  the  patient  should  be  immediately 
prepared  for  operation.  In  addition  to  the  usual  preparation,  the 
patient,  if  in  severe  shock,  should  be  given  morphine  j  grain  and 
strychnine  ^V,  grain  half  an  hour  before  the  operation.  Fifteen  minutes 
later  he  should  have  an  enema  of  hot  coffee,  which  should  be  held 
in  the  rectum  until  his  removal  to  the  operating-table.  When  the 
patient  is  etherized,  an  intravenous  saline  infusion  should  be  started 
before  the  abdomen  is  opened;  or  better  still,  in  cases  of  profound 

1  On  two  occasions  the  author  has  found  on  exploratory  laparotomy  complete  rupture 
of  the  small  intestine,  the  only  indications  of  which  were  the  history  of  injury,  a  rapid 
pulse,  and  slight  tenderness  and  rigidity  of  the  abdominal  wall.  On  another  occasion 
a  transverse  rupture  of  the  spleen  was  found  with  over  a  quart  of  free  blood  in  the  peri- 
toneal cavity,  in  an  individual  who  had  walked  a  mile  after  the  accident  and  complained 
only  of  slight  abdominal  pain  and  tenderness.  There  was,  however,  in  each  instance, 
marked  muscular  rigidity. 


CONTUSIONS  503 

shock  associated  with  evidences  of  grave  hemorrhage,  direct  trans- 
fusion of  blood  just  prior  to  operation  will  often  render  a  moribund 
patient  operable.  When  the  symptoms  point  to  no  definite  locality, 
a  median  incision  should  be  made  and  the  peritoneal  cavity  explored. 
If  gas  or  free  blood  escapes  when  the  peritoneum  is  opened,  the  ab- 
dominal incision  should  be  widely  extended  and  a  search  instituted 
for  the  injured  viscus.  In  the  presence  of  free  gas  or  intestinal  content-. 
the  stomach  should  be  drawn  into  the  wound  and  inspected,  after 
which  the  colon  should  be  examined  from  the  cecum  to  the  rectum. 
If  no  lesion  is  found,  the  small  intestine  should  be  lifted  out  of  the 
abdominal  cavity,  covered  with  warm  wet  towels,  and  the  entire 
length  of  the  gut  inspected  from  the  duodenum  to  the  ileocecal  valve. 
When  the  lesion  is  found,  it  should  be  repaired  if  possible  by  one  or 
more  silk  Lembert  sutures.  If,  in  case  of  an  intestinal  injury,  the 
wound  is  too  extensive  to  be  closed  in  this  way  without  causing 
stricture,  the  injured  area  should  be  excised  and  the  ends  united  by 
a  Murphy  button  or  one  of  the  suture  methods  of  end-to-end  anas- 
tomosis. If  on  opening  the  peritoneum  hemorrhage  only  is  present. 
the  liver  and  spleen  should  first  be  examined  for  evidences  of  rupture. 
If  no  injury  to  these  organs  is  found,  the  mesentery,  greater  and  lesser 
omentum,  vena  cava,  pelvic  vessels,  and  abdominal  parietes  are  ex- 
amined in  the  order  given.  This  examination  is  greatly  facilitated  by 
removal  of  the  small  intestine  from  the  cavity  and  the  use  of  large 
gauze  sponges  in  sponge-holders  to  wipe  away  the  blood  from  the 
various  parts  of  the  abdomen. 

Rupture  of  the  liver  should  be  treated  by  suture  of  the  rent  where 
this  is  possible.  Mattress  sutures  of  heavy  catgut  should  be  employed, 
introduced  by  a  blunt  curved  needle  or  by  a  curved  silver  probe,  the 
needle  or  probe  entering  the  hepatic  tissue  at  a  considerable  distance 
from  the  edge  of  the  fissure.  Where  this  is  impossible,  or  would  require 
too  much  time  or  manipulation,  the  use  of  generous  gauze  tamponnade 
is  to  be  advised.  As  the  rent  is  frequently  on  the  diaphragmatic 
surface  of  the  right  lobe,  along  the  falciform  or  coronary  ligaments, 
the  abdominal  wall  should  be  forcibly  retracted  and  the  right  lobe 
of  the  liver  gently  depressed  in  order  to  place  the  gauze  around  the 
injured  area.  In  case  a  median  incision  is  employed,  a  separate  incision 
should  be  made  along  the  lower  costal  border,  through  which  the 
external  portion  of  the  gauze  should  protrude.  If  allowed  to  emerge 
through  the  median  incision,  its  removal  would  tend  to  draw  downward 
the  right  lobe  of  the  liver  and  thus  reopen  the  fissure. 

An  injured  spleen  generally  can  be  drawn  into  the  wound  and  its 
ruptured  surface  united  with  sutures.  If  this  is  impossible  on  account 
of  the  condition  of  the  patient  the  surgeon  has  the  choice  of  two 
methods,  either  to  perform  a  rapid  splenectomy,  or  to  press  a  large 
mass  of  gauze  into  the  rent  and  replace  the  organ,  allowing  the  outer 
extremity  of  the  gauze  to  protrude  through  a  lower  lumbar  opening. 
As  soon  as  the  abdominal  wound  is  closed  the  pressure  of  the  other 


504  INJURIES  OF   THE  ABDOMEN 

viscera  causes  the  external  surface  of  the  spleen  with  its  mass  of 
gauze  packing  to  press  against  the  diaphragm,  preventing  further 
hemorrhage.  The  author  has  found  this  latter  method  quicker  than 
any  other,  and  has  always  succeeded  by  it  in  arresting  hemorrhage. 
It  has  the  additional  advantage  of  saving  an  important  organ.  After 
the  source  of  the  hemorrhage  is  found  and  secured,  the  abdominal 
cavity  should  be  flushed  with  a  large  amount  of  hot  saline  solution, 
and  the  wound  closed  with  layer,  or  through-and-through  silkworm- 
gut  sutures.  The  gauze  packing  should  be  allowed  to  remain  in  place 
for  from  seven  to  ten  days.  It  should  be  removed  under  anesthesia, 
and  a  small  wick  of  gauze  inserted  in  the  lower  portion  of  the  wound. 
In  injuries  of  the  omentum  or  mesentery,  the  bleeding  vessels  should 
be  secured,  any  large  rents  sutured,  and  devitalized  portions  of  the 
omentum  removed.  Intestinal  resection  may,  rarely,  be  indicated 
when  the  larger  branches  of  the  mesenteric  arteries  are  involved. 
Success  in  these  cases  will  depend  largely  upon  the  speed  of  operation, 
the  skill  of  the  anesthetist  in  administering  only  a  small  amount  of 
ether,  and  upon  the  judicious  employment  of  stimulating  measures, 
especially  the  intravenous  saline  infusion.         » 

Wounds  of  the  Abdomen. — Wounds  of  the  abdomen  are  divided  into 
two  classes:  non-penetrating  wounds,  or  those  involving  only  the  ab- 
dominal parietes  without  opening  the  peritoneal  cavity;  and  'pene- 
trating wounds,  or  those  which  open  the  peritoneum.  The  non-pene- 
trating wounds  differ  in  no  way  from  wounds  of  the  soft  parts  in  other 
regions  of  the  body,  with  the  exception  that  severed  muscles  and 
aponeuroses,  if  not  accurately  united,  will  often  lead  to  a  weakening 
of  the  abdominal  wall  and  favor  the  subsequent  occurrence  of  hernia. 
Every  wound,  therefore,  involving  one  of  these  tissues  should  be 
carefully  disinfected  and  accurately  united  by  layer  suture  with  a 
view  to  obtaining  primary  union. 

Penetrating  Wounds. — Penetrating  wounds  of  the  abdomen  are,  for 
the  most  part,  caused  by  stabs  or  gunshot  injuries.  Explosions,  railway 
accidents,  and  attacks  by  bulls  or  other  infuriated  animals,  furnish  a 
few  examples,  but  they  are  so  rare  as  to  be  justly  regarded  as  surgical 
curiosities. 

Symptoms. — As  in  the  case  of  abdominal  contusions,  the  symptoms 
of  penetrating  abdominal  wounds  depend  upon  the  presence  and 
character  of  the  associated  visceral  injury.  If  the  wound  is  a  small 
one  and  involves  only  one  of  the  solid  organs,  as  the  liver  or  spleen, 
and  is  unaccompanied  by  severe  hemorrhage,  there  may  be  no  symp- 
toms other  than  those  of  the  superficial  cut.  This  is  also  the  case 
in  certain  wounds  of  the  alimentary  canal,  especially  those  made  by 
the  steel  bullets  of  the  modern  high  velocity  fire-arms,  as  the  small, 
clean-cut  wound  is  often  plugged  by  a  prolapse  of  the  mucous  mem- 
brane, allowing  little  or  no  extravasation  of  the  contents  of  the  gut. 
Part  of  the  danger  in  these  cases  is  therefore  due  to  the  presence  of 
septic  matter  introduced  from  without,  which  is  often  so  small  in 


WOUNDS  OF  THE  ABDOMEN  505 

amount  as  to  give  rise  to  only  a  localized  peritonitis.  In  wounds 
involving  the  pancreas  there  is  always  the  added  danger  that  the 
extravasated  pancreatic  fluid  will  produce  a  fat-necrosis  in  the 
neighboring  parts,  which  if  infected  will  lead  to  extensive  suppuration 
and  a  high  degree  of  toxemia.  In  more  extensive  wounds  accompanied 
by  a  large  amount  of  hemorrhage  or  the  extravasation  of  a  considerable 
amount  of  infected  material  from  a  wound  of  the  stomach  or  intestine, 
the  symptoms  are  those  of  shock:  pallor,  weakness,  a  rapid,  feeble 
pulse,  restlessness,  thirst,  subnormal  temperature,  and  cold  perspira- 
tion, with  localized  tenderness  and  muscular  rigidity.  Later,  the 
temperature  rises,  vomiting  occurs,  and  if  the  patient  survives  the 
first  shock,  symptoms  of  progressive  general  peritonitis  will  develop. 
In  larger  abdominal  wounds  protrusion  of  the  intestine,  omentum,  and 
sometimes  of  other  intra-abdominal  organs  may  take  place.  In  many 
of  these  cases  the  shock  is  comparatively  slight,  and  instances  are  on 
record  in  which  individuals  have  walked  for  a  considerable  distance 
with  extensive  visceral  protrusions. 

Treatment. — All  penetrating  abdominal  wounds  should  be  explored 
immediately  under  general  anesthesia,  if  the  surgeon  is  in  a  position 
to  conduct  the  operation  with  competent  assistants  under  conditions 
of  strict  asepsis.  Protruding  viscera  should  be  thoroughly  cleansed 
before  being  returned  to  the  abdominal  cavity,  and  the  original  wound, 
when  favorably  situated,  should  be  sufficiently  enlarged  to  permit 
thorough  inspection  of  the  damaged  area.  If  free  blood  or  extrav- 
asated stomach  or  intestinal  contents  are  seen,  the  wound  should  be 
extended,  or  another  incision  should  be  made  in  a  more  favorable 
locality  and  the  source  of  the  hemorrhage  found  or  the  wounded  viscus 
located.  The  same  principles  should  guide  the  surgeon  in  the  treatment 
of  these  conditions  as  under  other  circumstances:  hemorrhage  should 
be  arrested  by  ligature  of  the  bleeding  vessel  or  by  gauze  packing; 
injuries  of  the  hollow  viscera  should  be  sutured,  after  which  the  entire 
peritoneal  cavity  should  be  flushed  with  salt  solution  and  the  wound 
closed  with  drainage.  In  stab  wounds  the  injury  will  be  limited  to  the 
immediate  vicinity  of  the  wound;  in  gunshot  wounds  the  injuries  are 
generally  multiple  and  widely  separated,  and  in  these  cases  the 
incision  should  be  sufficiently  large  to  enable  the  surgeon  to  inspect 
thoroughly  every  part  of  the  abdominal  cavity.  In  gunshot  wounds 
involving  the  stomach,  the  posterior  wall  invariably  should  be  inspected, 
and  in  wounds  of  the  pancreas  provision  should  be  made  for  adequate 
drainage  of  the  pancreatic  secretion.  It  frequently  happens  that  the 
bullet  will  so  injure  the  intestine  that  resection  will  be  necessary. 
As  in  operations  for  ruptures  of  the  viscera,  the  surgeon  should  work 
quickly  and  methodically,  as  prolonged  exposure  on  the  operating- 
table  is  sure  to  add  to  the  shock,  which  in  many  of  these  cases  is  severe 
at  the  outset.  The  hypodermic  injection  of  camphor  and  strychnine, 
coffee  enemata,  and  intravenous  saline  infusions  often  are  necessary 
while  the  patient  is  on  the  table. 


506  INJURIES  OF   THE  ABDOMEN 

The  after-treatment  of  these  cases  is  of  the  greatest  importance. 
Shock  should  be  combated  by  judicious  stimulation;  food  should 
be  withheld  for  twenty-four  or  forty-eight  hours  and  then  gradually 
administered  by  rectum  or  mouth,  and  pain  should  be  quieted  by 
some  form  of  opiate.  In  cases  of  injury  of  the  alimentary  canal, 
if  the  symptoms  are  favorable,  the  bowels  should  be  confined  for  four 
or  five  days.  If  peritoneal  sepsis  develops,  early  intestinal  drainage 
by  free  catharsis  should  be  induced.  When  the  peritoneum  has  been 
severely  contaminated,  the  surgeon  should  be  on  the  lookout  for  signs 
of  localized  peritonitis,  and  collections  of  pus  should  be  opened  and 
drained  as  soon  as  discovered.  If  the  case  exhibits  signs  of  progres- 
sive sepsis,  intravenous  infusions  frequently  repeated,  rectal  salines 
or  irrigations,  free  catharsis,  and  the  hypodermic  administration  of 
strychinine,  digitalin,  camphor  oil  or  pituitrin,  and  an  abundance  of 
nourishing  food  will  be  necessary. 

It  frequently  happens  in  both  military  and  civil  practice  that 
abdominal  wounds  have  to  be  treated  under  conditions  in  which 
perfect  aseptic  technic  cannot  be  carried  out.  Under  these  circum- 
stances small  penetrating  wounds,  especially  when  produced  by  the 
modern  high  velocity  firearms,  are  better  left  to  nature,  than  to  add 
the  risk  of  an  exploration  under  conditions  of  imperfect  technic. 
In  cases  of  severe  hemorrhage  and  large  penetrating  wounds  with 
extensive  visceral  injury  the  surgeon  must  act  even  under  the  most 
adverse  conditions.  Generous  gauze  drainage  of  the  abdominal  cavity 
will  often  assist  in  overcoming  the  infection  necessarily  produced  in 
these  cases. 


CHAPTER   XXI. 
DISEASES  OF  THE  ABDOMEN. 

Cellulitis. — Cellulitis  of  the  abdominal  wall  occurs  as  a  result  of 
wounds,  the  bites  of  insects,  and  from  inflammatory  conditions  about 
the  umbilicus  caused  by  infection  of  an  unclosed  urachus  or  vitello- 
intestinal  duct.  It  also  occurs  as  an  extension  outward  of  an  intra- 
abdominal septic  focus,  reaching  the  surface  through  the  inguinal 
canal,  or  by  direct  infiltration  of  the  muscular  layers.  The  symptoms 
and  treatment  are  the  same  as  in  cellulitis  in  other  parts  of  the  body. 

Congenital  Umbilical  Fistulse. — Congenital  umbilical  fistula?  are 
occasionally  encountered.  They  are  of  two  kinds,  the  urinary  and 
fecal.  The  former  are  due  to  the  persistence  of  the  urachus;  the 
latter,  to  a  failure  of  complete  closure  of  the  vitello-intestinal  duct 
which  may  lead  direct  to  the  intestine  or  to  a  Meckel's  diverticulum. 
As  a  rule,  the  opening  is  minute  and  only  a  small  amount  of  fluid 
exudes.  The  character  of  the  fluid  is  often  apparent  by  the  odor, 
or  it  can  be  determined  by  chemical  or  microscopic  examination. 

Treatment. — The  treatment  of  these  cases  should  aim  to  effect  a 
permanent  closure  of  the  opening.  This  sometimes  may  be  accom- 
plished by  cauterization,  which  destroys  the  mucous  membrane  and 
leaves  a  scar  which  subsequently  contracts  and  obliterates  the  canal. 
If  this  fails,  a  fine  probe  should  be  introduced  into  the  canal,  an 
incision  made  in  the  direction  of  the  probe,  the  duct  isolated  and 
ligated  with  fine  chromicized  catgut,  and  the  distal  end  cut  off  and 
cauterized,  after  which  the  cutaneous  wound  should  be  disinfected 
and  closed  with  sutures.  When  the  fistula  communicates  with  the 
lumen  of  a  Meckel's  diverticulum,  laparotomy  and  removal  of  the 
diverticulum  are  indicated. 

TUMORS  OF  THE  ABDOMINAL  WALL. 

Primary  malignant  tumors  of  the  abdominal  wall  are  rare.  Epi- 
thelioma and  sarcoma  have  been  reported,  the  former  generally 
occurring  at  the  umbilicus,  the  latter  growing  from  the  muscular 
or  fascial  planes.  Of  the  benign  tumors,  which  are  of  more  frequent 
occurrence,  lipomata  are  perhaps  the  commonest,  the  others  in  the 
order  of  frequency  being  angiomata,  fibroneuromata,  dermoid,  and 
other  cysts.  The  diagnosis  and  treatment  of  these  tumors  of  the 
abdominal  wall  present  no  special  features,  and  differ  in  no  respect 
from  the  diagnosis  and  treatment  of  like  tumors  in  other  parts. 


508  DISEASES  OF   THE  ABDOMEN 

Johannes  Miiller  in  1838  described  a  tumor  of  the  abdominal  wall 
which  he  termed  a  desmoid,  and  which  may  be  said  to  occupy  a  position 
between  the  malignant  and  innocent  growths.  It  is  a  "cellular 
fibroma,"  which  occurs  mostly  in  women  who  have  borne  children, 
and  generally  is  located  in  the  rectus  muscle.  It  is  round,  ovoid, 
or  oblong  in  shape;  if  often  arises  from  the  fibrous  sheath,  and  occasion- 
ally has  bony  attachments.  It  grows  rapidly  at  times  and  may  reach 
the  size  of  an  orange  or  cocoanut.  According  to  Pfeifl'er  33  per  cent, 
recur  after  operation.    The  treatment  should  be  early  radical  removal. 

DISEASES  OF  THE  PERITONEUM. 

The  peritoneum  lines  the  abdominal  cavity,  and  is  the  largest 
serous  sac  in  the  body.  Its  area  of  surface  is  nearly  equal  to  that 
of  the  integument.  Its  surfaces,  lined  with  a  single  layer  of  endothe- 
lium, are  everywhere  in  contact,  a  capillary  space  existing  between 
them  normally  with  only  enough  fluid  for  purposes  of  lubrication.  It 
closely  invests  the  abdominal  parietes  and  the  intra-abdominal  organs 
over  which  it  is  reflected,  forming  a  complete  investment  for  some 
and  a  partial  investment  for  others.  Certain  parts  of  the  abdominal 
cavity  are  separated  from  the  rest  in  a  measure  by  its  folds,  a  fact 
which  has  its  practical  surgical  significance,  as  peritonitis  occurring 
in  those  sites,  is  more  apt  to  become  localized  and  prevented  from 
spreading  to  other  parts  of  the  peritoneal  cavity,  as  the  lesser 
omental  cavity,  the  subphrenic  space. 

The  absorptive  power  of  the  peritoneum  is  very  great :  large  quantities 
of  fluids  can  be  taken  up  with  great  rapidity.  It  is  known  that  con- 
siderable quantities  of  bacteria  or  toxic  materials  can  be  obsorbed 
and  taken  care  of  by  the  normal  peritoneum  without  causing  peri- 
tonitis. It  has  also  been  shown  that  virulent  bacteria  introduced  into 
the  peritoneal  cavity  of  animals  for  experimental  purposes  can  be 
demonstrated  in  the  blood  stream  within  a  very  few  moments,  showing 
the  probability  that  in  more  acute  and  fatal  forms  of  peritoneal  sepsis, 
death  is  due  rather  to  a  general  bacteriemia  and  septicemia,  than  to 
peritoneal  inflammation. 

It  has  been  shown  that  this  absorptive  power  is  greater  in  the 
upper  abdominal  cavity  in  the  region  of  the  diaphragm  than  in  the 
lower  abdomen. 

The  parietal  peritoneum  is  abundantly  supplied  with  sensory  nerve 
endings,  which  are  absent  in  the  visceral  peritoneum.  For  this  reason, 
tenderness  and  muscular  rigidity  are  very  early  signs  when  an  inflam- 
matory process  first  involves  structures  in  contact  with  the  anterior 
parietes,  but  are  later  in  developing  when  the  initial  inflammation 
is  deep-seated  and  separated  from  the  anterior  parietes  by  coils  of 
intestines,  or  viscera  not  yet  involved. 

The  reparative  power  of  the  peritoneum  is  not  exceeded  by  that  of 
any  structure  in  the  body;  it  is  peculiar  in  that  the  condition  most 


DISEASES  OF  THE  PERITONEUM  509 

favorable  for  the  rapid  repair  of  wounds  is  not  the  accurate  apposi- 
tion of  cut  surfaces,  but  rather  contact  of  free  endothelial  surfaces 
which  have  been  irritated  or  traumatized,  or  merely  held  firmly  in 
contact  by  sutures  or  other  means.  To  counteract  the  influence  of 
irritants  of  various  sorts,  there  is  a  rapid  exudation  of  fibrinous  lymph 
which  glues  the  surfaces  together.  ^Yhen  the  irritation  is  slight,  and 
of  short  duration,  this  may  be  completely  absorbed,  leaving  the  sur- 
faces again  normal.  If  of  a  more  marked  degree,  or  of  longer  dura- 
tion, permanent  adhesions  may  result.  It  is  by  this  process  that 
protective  adhesions  form  around  a  focus  of  infection  and  tend  to 
localize  the  area  of  inflammation. 

Acute  Peritonitis. — This  may  occur  as  a  non-infective,  or  an  infective 
process. 

Non-Infective  Peritonitis. — Non-infective  peritonitis  may  be  caused 
by  effusions  of  blood,  as  of  an  ectopic  pregnancy,  ruptured  spleen 
or  liver;  by  the  escape  of  sterile  contents  of  intra-abdominal  cysts; 
by  non-infective  bile,  as  from  contact  in  the  course  of  operations  on  the 
biliary  passages;  by  trauma,  as  in  severe  contusions  of  the  abdomen 
without  rupture  of  viscera;  by  trauma  in  the  course  of  operations;  by 
contact  with  chemical  irritants,  as  strong  antiseptic  solutions;  by  the 
presence  of  aseptic  foreign  bodies  in  the  peritoneal  cavity,  such  as 
gauze  pads,  instruments,  etc. 

The  exudate  is  serous  or  fibrinous,  and  may  be  completely  ab- 
sorbed when  the  source  of  irritation  is  removed.  It  may  result  in  the 
formation  of  temporary  or  permanent  adhesions;  or,  it  may  become 
infected  from  the  passage  of  bacteria  through  the  intestinal  walls,  or 
from  the  blood  stream,  and  the  character  of  the  process  thus  changed 
to  an  infective  type;  thus  aseptic  foreign  bodies  (gauze  pads)  may 
become  encysted  by  adhesions  and  remain  sterile;  or,  infection  may 
occur  with  the  formation  of  abscesses,  sinuses,  or  fistula3. 

A  certain  amount  of  non-infective  peritonitis  resulting  from  the 
process  of  handling  peritoneal  surfaces  during  abdominal  operations 
probably  occurs  after  every  abdominal  operation,  and  is  generally  a 
negligible  factor  in  convalescence.  Severe  manipulation,  rough  use 
of  gauze  sponges,  or  contact  with  strong  chemical  irritants  may, 
however,  result  in  paralysis  of  the  intestines,  formation  of  adhesions, 
and  be  a  serious  factor  in  the  postoperative  course.  It  is  also  of 
importance  from  the  fact  that  traumatized  or  irritated  peritoneum  is 
less  able  to  resist  bacterial  infection,  and  thus  serious  postoperative 
infective  peritonitis  may  follow  operations  involving  much  peritoneal 
trauma  with  relatively  slight  bacterial  contamination,  when  with  less 
trauma,  a  similar  amount  of  contamination  could  be  easily  cared  for 
by  absorption  without  untoward  result. 

Again,  when  associated  with  intestinal  paralysis,  due  to  much 
handling  of  the  intestine,  the  change  to  a  serious  infective  type  of 
postoperative  peritonitis,  may  be  caused  by  the  passage  of  germs 
through  the  damaged  intestinal  wall. 


510  DISEASES  OF   THE  ABDOMEN 

Infective  Peritonitis. — Etiology.  —  Infective  peritonitis  is  due  to 
bacterial  infection  of  the  peritoneal  cavity,  and  may  be  localized, 
spreading,  or  general.  It  may  be  due  to  wounds  of  the  abdominal 
parietes,  or  to  penetrating  wounds  involving  intra-abdominal  viscera; 
to  rupture  of  intra-abdominal  viscera  from  crushing  injuries,  as  the 
intestine  or  bladder;  to  perforating  lesions  of  intra-abdominal  organs, 
the  vermiform  appendix  being  by  far  the  most  frequent  offender; 
perforated  ulcers  of  the  stomach  or  duodenum;  perforated  typhoid 
ulcers;  perforated  ulcers  of  the  cecum  or  colon;  diverticulitis  of 
sigmoid  with  perforation;  localized  gangrenous  processes  from 
strangulation,  as  in  hernia?;  from  mesenteric  thrombosis,  or  intussus- 
ception; from  gangrene  of  the  gall-bladder,  or  ulceration  caused  by 
foreign  bodies. 

Peritonitis  may  occur  with  any  of  the  above  lesions  by  extension 
of  the  infection  through  the  inflamed  or  necrotic  wall  of  the  viscus 
without  actual  perforation.  It  may  be  due  to  suppurative  lesions 
of  adjacent  organs  or  structures,  such  as  infective  lesions  of  the  liver, 
gall-bladder,  pancreas,  spleen,  kidney,  Fallopian  tubes,  ovaries  or 
uterus;  retroperitoneal  infective  processes,  or  even  to  suppurative 
processes  in  the  thorax. 

Of  the  bacteria  causing  peritonitis,  the  streptococcus  pyogenes 
is  most  frequently  responsible  for  the  virulent  types.  Staphylococcus 
pyogenes  aureus;  colon  bacillus  which  is  present  in  all  cases  due  to 
perforative  lesions  of  the  gastro-intestinal  tract,  but  often  associated 
with  other  organisms;  the  gonococcus;  pneumococcus;  the  typhoid 
bacillus;  occasionally  the  bacillus  pyocyaneous;  and  also  the  tubercle 
bacillus  which  produces  the  particular  form  of  peritonitis  to  be 
described  later. 

Pathology. — Infective  peritonitis  may  be  localized,  diffuse,  or  general, 
depending  upon  the  virulence  of  the  infective  organism,  the  amount 
of  infective  material  introduced,  the  rapidity  of  its  introduction,  the 
location  of  the  infection,  and  the  degree  of  resistance  of  the  individual. 

When  the  infective  material  is  small  in  amount,  of  moderate  viru- 
lence, and  not  introduced  too  rapidly,  localized  peritonitis  results. 
The  protective  power  of  the  peritoneum  is  stimulated,  fibrinous  exudate 
is  thrown  out  in  abundance  around  the  infected  focus,  the  omentum 
finds  its  way  at  once  to  the  point  of  irritation,  the  intestinal  coils 
adhere  and  aid  in  forming  a  barrier.  Examples  of  this  type  are  of 
the  commonest  occurrence,  as  in  small  perforations  of  the  appendix 
which  contain  little  infective  material,  a  little  leakage,  rapid  forma- 
tion of  protective  adhesions  which  soon  occlude  the  minute  perforation, 
and  at  some  future  operation  the  evidence  of  the  process  is  found 
only  in  the  remaining  adhesions.  A  similar  process  may  occur  with 
gastric  or  duodenal  ulcer. 

The  next  step  in  the  process  is  when  the  infection  is  a  degree  more 
virulent,  the  infective  material  more  abundant,  or  the  resistance 
less  effective.    Adhesions  form  but  are  forced  back  by  the  enlarging 


DISEASES  OF   THE  PERITONEUM  511 

abscess  over  a  wider  and  wider  area  until  relief  is  obtained  by  incision, 
or  there  is  a  rupture  of  the  abscess  into  the  intestine,  or  through  the 
wall  of  the  adhesions  into  the  free  peritoneal  cavity,  causing  diffuse 
peritonitis. 

Diffuse  Peritonitis. — Diffuse  peritonitis  is  a  term  rather  loosely 
applied  to  cases  of  varying  extent,  which  do  not  involve  the  entire 
abdominal  cavity.  Always  serious,  it  varies  greatly  in  its  virulence 
and  fatality,  in  the  balance  between  the  intensity  of  the  infection  and 
the  resistance  of  the  individual. 

The  exudate  may  vary  in  character  in  different  parts  of  the  affected 
area.  At  the  site  of  the  focus  of  infection,  there  may  be  true  abscess, 
often  with  fecal  odor,  partly  or  completely  surrounded  by  adhesions; 
in  the  next  zone  purulent  exudate  with  flakes  of  fibrin  without  offen- 
sive odor,  partly  limited  by  adhesions;  still  further  away,  slightly 
cloudy  serous  effusion,  cultures  from  which  are  often  sterile. 

A  variety  of  diffuse  peritonitis  known  as  "progressive  fibrino- 
purulent  peritonitis"  is  characterized  by  collections  of  pus  almost 
completely  separated  by  massive  fibrinous  exudate,  adherent  coils  of 
intestine  and  omentum.  This  type  has  a  tendency  to  spread  from 
one  part  of  the  abdomen  to  another,  and  is  a  serious  and  often  fatal 
form  of  peritonitis,  but  may  be  controlled  by  evacuation  and  drainage 
of  the  separate  collections  of  pus  as  soon  as  they  can  be  recognized. 

In  the  virulent  forms  of  acute  peritoneal  sepsis,  due  to  gangrenous 
appendicitis,  gangrene  of  the  gall-bladder,  or  seen  in  the  postoperative 
type,  the  surface  of  the  peritoneum  loses  its  lustre,  becomes  slightly 
congested,  but  there  may  be  little  or  no  serous  or  fibrinous  exudate. 

In  the  fulminating  cases,  resulting  in  death  within  twenty-four  or 
forty-eight  hours,  the  infection  is  overwhelming  from  the  beginning 
and  the  resisting  powers  of  the  peritoneum  are  paralyzed,  the  whole 
picture  being  one  of  a  violent  general  toxemia  rather  than  a  peritoneal 
inflammation. 

Peritonitis  arising  from  inflammation  of  the  uterus  or  Fallopian 
tubes,  if  of  a  puerperal  origin,  or  following  uterine  instrumentation, 
is  usually  due  to  a  streptococcus,  is  of  a  high  degree  of  virulence,  and 
more  the  type  of  a  septicemia  than  of  a  mere  peritoneal  inflammation. 
If  due  to  a  gonococcus,  the  inflammatory  reaction  and  constitutional 
symptoms,  are  often  violent  at  the  onset,  but  soon  become  subacute, 
or  chronic;  the  amount  of  fibrinous  exudate  is  generally  great,  and 
resulting  adhesions  extensive,  but  confined  to  the  pelvis  and  lower 
abdomen.  Abscess  formation  may  or  may  not  take  place.  The  process 
is  rarely  generalized. 

Symptoms. — Symptoms  of  peritonitis  vary  in  severity  and  in  the 
preponderance  of  certain  features,  according  to  the  type  of  the 
process,  the  causative  lesion,  the  age  and  resistance  of  the  patient, 
and  the  virulence  of  the  infection.  Thus,  in  acute  peritoneal  sepsis, 
the  symptoms  of  severe  septic  intoxication  often  overshadow  com- 
pletely the  local  symptoms.     Certain  cardinal  symptoms,  however,  are 


512  DISEASES  OF   THE  ABDOMEN 

present  in  nearly  all  cases.  In  the  order  of  their  development  and 
diagnostic  importance  we  may  consider  the  following:  pain,  vomiting, 
tenderness,  muscular  rigidity,  elevation  of  pulse  rate,  and  generally 
of  temperature,  leukocytosis,  and  some  degree  of  prostration.  Added 
to  these,  as  the  disease  progresses,  may  be  abdominal  distension, 
hiccough,  restlessness  and  anxiety,  or  cerebral  symptoms;  signs  of 
free  peritoneal  fluid;  and,  if  the  process  becomes  localized,  or  partly 
so,  tumor,  caused  by  inflammatory  exudate  or  abscess. 

Pain  is  the  initial  symptom,  and  is  constant.  In  perforative  lesions 
it  may  be  of  great  violence,  and  accompanied  by  prostration  or  collapse. 
Its  site  at  the  onset  often  is  indicative  of  the  cause  of  the  peritonitis. 
The  initial  pain,  however,  is  not  always  directly  at  the  site  of  the 
causative  lesion,  as  in  perforative  appendicitis,  the  initial  pain  may 
be  in  the  epigastrium,  or  at  the  navel,  shifting  later  to  the  right  iliac- 
fossa. 

The  pain  of  peritonitis  in  many  instances  is  preceded  by  the  pain 
of  the  causative  lesion,  but  generally,  the  change  in  character  and 
severity  with  the  onset  of  peritonitis  is  abrupt  and  not  difficult  to 
recognize.   With  severe  peritoneal  sepsis,  pain  may  be  slight,  or  absent. 

Vomiting,  as  a  rule,  quickly  follows  the  onset  of  the  pain.  It  is  first 
of  stomach  contents;  later,  if  persistent,  of  watery  bile-tinged  fluid; 
of  brownish-colored  material;  or,  finally,  of  intestinal  contents.  In 
the  mild  and  localized  cases,  it  may  be  present  only  at  the  onset  and 
soon  ceases.  In  severe  progressive  cases,  it  becomes  almost  constant, 
a  regurgitation,  or  overflow,  with  little  apparent  effort.  Only  in 
exceptional,  or  very  mild  cases,  is  vomiting  absent. 

Tenderness  on  pressure  quickly  follows  the  onset  of  pain;  and  if  the 
process  involves  the  parietal  peritoneum,  it  is  accompanied  by  muscular 
rigidity.  Tenderness  is  at  first  limited  at  the  site  of  the  initial 
lesion,  spreading  from  there  to  other  portions  of  the  abdomen.  With 
muscular  rigidity,  it  is  the  most  valuable  diagnostic  sign,  and  the  most 
reliable  indicator  of  the  site  of  the  causative  lesion.  Increase  in  an 
area  of  tenderness  and  rigidity,  means  diffusion  of  the  peritonitis. 
The  most  extreme  degree  of  rigidity  is  seen  with  perforative  gastric  or 
duodenal  ulcer,  and  is  described  as  "board-like." 

Rigidity,  even  of  a  slight  degree,  over  the  appendix,  gall-bladder, 
duodenum  or  stomach,  sigmoid,  or  ileum  in  typhoid,  is  a  warning  of 
beginning  peritonitis,  and  if  detected  early,  may  allow  of  surgical 
intervention  before  actual  perforation  or  serious  spreading  peritonitis 
supervenes. 

Rigidity  may  be  slight,  or  absent,  in  the  fulminating  forms  of 
peritonea]  sepsis;  in  some  rapidly  fatal  cases  of  postoperative  perito- 
nitis; and  occasionally  in  wide-spread  peritonitis  with  a  purulent 
exudate  of  mild  virulence. 

The  [jtilse  rate  rapidly  rises  in  peritonitis;  the  quality,  at  first 
good,  as  the  peritonitis  progresses,  becomes  weak,  thready,  and 
compressible.     The  change  in  rate  and  character  of  the  pulse  is  a 


DISEASES  OF  THE  PERITONEUM  513 

much  more  constant  and  valuable  diagnostic  sign  than  a  change  in 
the  temperature.  It  is  important  to  note  the  relative  rate,  progressive 
increase  in  the  septic  cases  being  significant. 

Elevation  of  temperature,  as  a  rule,  accompanies  the  onset  of  perito- 
nitis. There  is  no  typical  temperature  curve,  however,  and  the  absence 
of  fever,  or  a  very  slight  rise  in  temperature  counts  little  against  the 
diagnosis  of  peritonitis,  if  other,  more  important  signs  are  present. 
The  subnormal  temperature,  when  associated  with  a  rapid,  weak  pulse 
and  some  degree  of  cyanosis,  is  of  grave  significance. 

Chills  are  rarely  present  during  the  course  of  peritonitis.  They 
occasionally  occur  at  the  onset,  especially  if  some  gangrenous  process 
is  present. 

Leukocytosis  is  regularly  present,  and  with  the  advance  of  the  process, 
rises.  The  actual  count  varies  much  in  different  cases,  and  is  of  less 
value  than  the  relative  amount  in  several  repeated  examinations. 

Prostration  may  be  mild,  or,  in  severe  forms  extreme  from  the  onset, 
especially  in  the  larger  perforative  lesions,  or  in  the  acute  forms  of 
peritoneal  sepsis. 

Distension,  or  meteorism,  is  present  to  a  greater  or  less  degree  in 
all  cases,  and  in  considerable  extent.  It  may  become  so  great  as 
to  embarrass  respiration  by  pressure  on  the  diaphragm.  It  is  greatly 
increased  by  the  taking  of  food,  or  by  cathartics  given  in  an  early 
stage  of  a  spreading  peritonitis.  It  is  due  to  decomposition  and 
fermentation  of  intestinal  contents,  and  to  paralysis  of  intestinal 
muscle. 

Hiccough  is  an  occasional  symptom,  not  present  in  all  cases,  but 
may  be  extremely  troublesome  and  persistent. 

In  advanced  cases  the  peritonitis  facies  is  quite  characteristic. 
The  face  pinched  and  drawn,  will  be  blue,  the  teeth  dry  and  covered 
with  sordes;  tongue  coated  and  tremulous.  Great  restlessness  and 
anxiety,  with  the  mind  alert  and  active,  is  the  characteristic  of  severe 
peritonitis  up  to  the  very  late  stages,  when  delirium,  stupor,  or  coma 
may  supervene.  One  frequently  sees,  however,  the  mental  condition 
clear  and  active  up  to  the  very  hour  of  death,  adding  greatl}r  to  the 
distress  of  the  condition. 

The  characteristic  attitude  of  the  patient  is  the  dorsal  position  with 
the  knees  drawn  up,  to  relieve  tension  on  the  abdominal  and  iliac 
and  psoas  muscles. 

Signs  of  free  peritoneal  fluid  are  often  absent,  and  of  little  value  in 
the  diagnosis.    Shifting  dulness  in  the  flank  may  indicate  its  presence. 

Cyanosis.,  with  cool,  clammy  skin,  is  a  late  symptom,  due  to  circula- 
tory failure,  and  to  lack  of  oxygenation  through  the  shallow  respiration. 

Tumor,  or  mass  indicates  localization  of  the  process,  partial  or 
complete,  and  is  due  to  agglutination  of  intestinal  coils  or  omentum, 
with  inflammatory  exudate,  or  the  actual  presence  of  pus. 

Diagnosis. — Usually  the  diagnosis  of  peritonitis  is  easily  made  from 
the  signs  and  symptoms  already  described.  Occasionally  the  various 
33 


514  DISEASES  OF   THE  ABDOMEN 

forms  of  colic  may  cause  confusion  in  the  early  stage,  as,  intestinal, 
nephritic,  gallstone,  or  lead  colic;  also  acute  gastro-enteritis,  or  intes- 
tinal obstruction.  Acute  pancreatitis  may  simulate  the  violent  forms 
of  peritonitis  due  to  perforative  lesions  of  the  upper  abdomen.  Acute 
septic  infarcts  of  the  kidney  may  be  mistaken  for  peritonitis  due  to 
an  acute  appendicitis. 

Symptoms  of  the  various  causative  lesions  already  enumerated 
may  merge  into  those  of  a  resultant  peritonitis,  the  onset  of  which, 
however,  is  generally  well  defined  by  the  abrupt  change  in  character 
or  intensity  of  the  symptoms. 

Course.  —  The  course  of  peritonitis  varies  greatly,  as  has  already 
been  indicated  in  discussing  the  symptoms.  Rapid  forms  of  peri- 
toneal sepsis  may  terminate  fatally  within  twenty-four  to  forty-eight 
hours.  The  more  usual  course  in  the  unfavorable  cases  is  for  the  symp- 
toms to  increase  gradually  in  severity  for  four  to  six  days  before 
resulting  fatally. 

In  the  progressive  fibropurulent  form  the  course  may  be  still 
slower.  Cases  terminating  in  localization  show  improvement  as  a 
rule  in  from  two  to  four  days. 

Prognosis. — The  prognosis  in  the  local  forms  is  generally  favorable 
if  proper  surgical  treatment  is  instituted,  or  if  the  type  is  one  which 
may  go  on  to  spontaneous  recovery.  In  the  diffuse,  advancing  forms, 
much  depends  upon  the  balance  between  the  severity  of  the  infection 
and  the  resistance  of  the  individual;  and  much,  also,  upon  the  intelli- 
gence with  which  treatment  is  directed. 

Generalized  peritonitis,  or  that  involving  all  portions  of  the  perito- 
neal cavity,  is  usually  fatal,  though  occasionally  recovery  may  occur, 
especially  in  children. 

Pneumococcus  peritonitis  is  a  rare  form  which  may  be  attended 
with,  or  follow  pneumonia,  or  may  occur  independently.  It  has  been 
most  frequently  observed  in  female  children,  and  is  thought  to  be  an 
hemotogenous  infection,  the  germs  reaching  the  peritoneum  directly 
from  the  blood  stream,  or  possibly  sometimes  by  way  of  the  lymphatics 
through  the  diaphragm.  It  is  usually  extensive  or  general  in  its  dis- 
tribution. The  exudate  is  purulent,  odorless,  often  containing  clots 
of  fibrin.  The  degree  of  septic  intoxication  is  as  a  rule  less  marked 
than  in  peritonitis  due  to  gangrenous  or  perforative  lesions. 

Complications. — Complications  of  peritonitis,  as  secondary  abscess, 
particularly  subphrenic  abscess,  are  really  variations  in  its  course 
and  localization;  other  complications  and  sequelae  depend  largely 
upon  adhesion  formation  and  its  resulting  pain  or  interference  with  the 
function  of  the  intestine,  stomach  or  biliary  ducts. 

Subphrenic  abscess  is  a  collection  of  pus  between  the  upper  surface 
of  the  liver  and  the  diaphragm,  more  often  to  the  right  than  to  the 
left  of  the  suspensory  ligament.  It  may  be  simply  the  extension  of  a 
progressive  fibrino-purulent  peritonitis,  or  secondary  to  suppurative 
appendicitis,  in  which  case  the  extension  may  ascend  directly  up  the 


DISEASES  OF   THE   PERITONEUM  515 

colonic  gutter,  or  be  carried  by  the  retroperitoneal  lymphatics.  It 
may  be  due  to  infective  lesions  of  the  liver  or  gall-bladder,  to  perfora- 
tion of  the  duodenum,  or  suppurative  lesions  of  the  right  kidney; 
or,  rarely,  to  perforation  of  the  diaphragm  by  an  empyema. 

Intestinal  saphrophites  occasionally  are  present,  especially  when  the 
abscess  is  secondary  to  intestinal  lesions,  giving  a  foul  odor  to  the 
exudate  and  quite  frequently  causing  the  formation  of  ga>  in  the 
abscess. 

The  symptoms  and  signs  of  subphrenic  abscess  in  a  typical  case 
are  quite  characteristic:  Persistent  and  slowly  rising  fever,  with  the 
constitutional  signs  of  unrelieved  sepsis.  Some  degree  of  immobility 
of  the  costal  arch  with  later  bulging  and  tenderness  on  pressure  over 
the  lower  rib^  on  the  affected  side;  increase  in  the  area  of  liver  dulness 
upward,  with  an  arched  upper  limit  to  the  dull  area,  sometimes  dis- 
placement downward  of  the  liver  margin.  Occasionally,  when  gas  is 
present,  tympanitic  resonance  and  succussion. 

Fluid  in  the  pleural  cavity  may  develop  secondarily  and  confuse 
the  signs,  and  differentiation  must  be  made  from  a  localized  empyema. 
Exploratory  puncture  should  be  performed  to  confirm  the  diagnosis. 

Treatment  consists  in  evacuation  and  drainage,  sometimes  possible 
at  the  costal  margin  below  the  pleura,  often  best  made  posteriorly 
at  about  the  tenth  space,  transpleural,  in  one  or  two  stages,  as  con- 
ditions seem  to  indicate. 

Treatment  of  Peritonitis. — First,  and  most  important,  is  the  pre- 
ventive treatment.  Early  recognition  of  the  various  causative  lesions, 
and  prompt  surgical  relief  of  the  same.  As  this  principle  is  recognized 
more  and  more,  for  example,  in  diseases  of  the  appendix,  gall-bladder, 
stomach,  and  duodenum,  cases  of  serious  peritonitis  become  fewer 
and  the  mortality  from  this  cause  greatly  diminished. 

Second,  inhibitive  treatment,  including  the  various  non-operative 
means  employed  to  limit  the  extent  of  the  peritonitis,  to  favor  its 
localization,  or  to  change  a  diffuse  spreading  type  to  a  localized  form; 
and  the  measures  employed  to  increase  the  general  response  of  the 
patient.  These  measures  consist  in  prohibition  of  food  or  fluids  by 
the  stomach,  or  catharsis  in  the  earlier  stages;  gastric  lavage  to 
check  vomiting;  salt  solution  by  the  rectum  to  replace  the  loss  in 
body  fluids;  ice-bags  or  cool  applications  externally;  and  sedatives 
for  the  pain,  used  sparingly,  and  not  at  all  at  the  onset  until  the  diag- 
nosis has  been  made,  on  account  of  the  great  danger  of  masking  the 
symptoms,  and  thereby  underestimating  the  gravity  of  the  condition. 

Third,  operative  treatment,  which  consists  of  the  removal  of  the 
existing  cause  when  possible;  removal  of  purulent  exudate  and  pro- 
vision for  drainage  of  areas  in  which  purulent  exudate  is  likely  to  con- 
tinue to  be  formed.  The  older  methods  of  operative  treatment,  with 
wide  incisions,  much  sponging  and  trauma  of  peritoneal  surfaces  and 
handling  of  intestinal  coils  in  the  effort  to  cleanse  the  infected  areas, 
were  attended  with  high  mortality.    The  whole  recent  technic  has  as 


516  DISEASES  OF  THE  ABDOMEN 

its  basis  a  minimum  of  trauma,  a  minimum  exposure  of  intra-abdominal 
contents,  removal  of  purulent  exudates  by  the  quickest  and  easiest 
methods,  relatively  small  incision,  quick  operation  and  proper  drain- 
age, the  latter  not  to  be  the  huge  gauze  packs  formerly  employed. 

Some  difference  of  opinion  exists  as  to  the  best  method  of  removing 
purulent  exudate.  Of  the  newer  methods,  some  form  of  suction 
apparatus  is  probably  the  best.  Irrigation,  with  large  quantities  of 
salt  solution  through  the  Blake  double  tube  in  cases  of  diffuse 
peritonitis,  has  been  widely  used,  and  with  excellent  result.  Simple 
evacuation  of  pus  with  gentle  sponging,  is  often  sufficient  in  the 
localized  cases  and  those  of  limited  extent. 

The  after-treatment  is  practically  a  repetition  of  the  treatment 
enumerated  under  the  head  of  "Inhibitive  Treatment."  Measures 
tending  to  prevent  peristalsis,  to  prevent  vomiting,  to  supply  the 
necessary  fluids  by  the  rectum,  and  thus  to  conserve  the  natural 
resistance  and  favor  localization  of  this  process  to  the  region  of  the 
operative  field;  saline  solution  by  hypodermoclysis  or  intravenous 
infusion  may  be  necessary  if  saline  by  the  rectum  is  not  well  borne. 
Vomiting  is  best  controlled  by  lavage;  distension  by  rectal  tube, 
irrigations  or  enemata.  The  Fowler  position  (sitting  almost  upright 
in  bed)  adds  to  the  comfort  and  safety  of  the  patient.  Opiates  should 
be  given  sparingly  for  the  relief  of  pain. 

Tuberculous  Peritonitis. — Tuberculous  peritonitis  may  be  primary 
or  secondary  to  disease  of  the  intestine,  Fallopian  tube,  retroperitoneal 
lymph  nodes,  or  to  mor,e  distant  tuberculous  lesions.  It  may  occur 
at  any  period  of  life,  but  is  most  common  in  young  adults.  It  occurs 
in  two  types: 

First,  the  ascitic  form,  with  free  accumulation  of  fluid,  and  numerous 
miliary  tubercles  scattered  over  both  visceral  and  parietal  peritoneum. 
The  omentum  is  generally  thickened  and  rolled  up  as  a  transverse 
mass  across  the  abdomen.  Intestinal  coils  may  mat  together  and 
form  palpable  tumors.  The  accumulation  of  fluid  is  usually  general, 
simulating  the  ascites  of  cirrhosis. 

Second,  the  caseating  form  in  which  there  is  much  matting  together 
of  intra-abdominal  contents  about  the  adhesions  and  masses  of  tuber- 
culous tissue  without  fluid.    This  is  the  less  common  form. 

Symptoms. — The  symptoms  of  tuberculous  peritonitis  are  exceed- 
ingly variable.  In  the  ascitic  variety  the  only  symptoms  may  be  a 
gradual  depression  of  health,  and  the  slow  development  of  ascites. 
In  other  cases  digestive  disturbances  may  be  present,  with  attacks 
of  colic  and  constipation,  alternating  with  diarrhea  resulting  in  wasting 
and  progressive  asthenia.  Fever  may  be  present  in  the  later  stages 
but  often  is  absent  early  in  the  disease.  Leukocytosis  is  absent. 
Tenderness  and  muscular  rigidity  are  slight,  or  absent,  as  a  rule.  Signs 
of  free  peritoneal  fluid  are  sometimes  the  first  indication  of  the  presence 
of  the  disease. 

In  the  caseating  form,  in  addition  to  the  above  symptoms,  one  or 


DISEASES  OF  THE  PERITONEUM  517 

more  irregular  tumors  are  detected  in  the  abdomen.  These  are  at 
first  movable  but  later  become  fixed  and  eventually  large  masses  can 
be  felt  which  resemble  malignant  disease.  Areas  of  fluctuation  some- 
times may  be  detected  and  muscular  rigidity  often  is  present.  The 
association  of  this  disease  with  pulmonary  tuberculosis  or  tuberculosis 
in  other  organs,  is  frequent,  and  in  the  later  stages  is  the  rule. 

Diagnosis. — The  diagnosis  of  tuberculous  peritonitis  is  not  always 
easy.  The  ascitic  variety  may  be  mistaken  for  ascites  due  to  cirrhosis 
of  the  liver,  or  to  ovarian,  parovarian,  or  other  cysts,  or  ascites  due 
to  peritoneal  carcinomatosis,  or  to  papillomatous  ovarian  neoplasms. 
From  cirrhosis  it  is  distinguished  by  the  absence  of  other  signs  of 
cirrhosis,  by  the  presence  of  one  or  more  intra-abdominal  nodules; 
by  its  slow  development,  and  by  the  presence  of  other  tuberculous 
deposits.  From  a  la'rge  abdominal  cyst  it  is  to  be  distinguished  by  the 
fact  that  there  is  flatness  in  the  flanks  while  the  patient  rests  on  the 
back,  with  resonance  over  the  centre  of  the  abdomen,  and  the  flatness 
can  be  made  to  change  its  position  by  moving  the  patient  on  the  side. 
In  large  cysts  of  the  abdomen,  on  the  other  hand,  the  centre  of  the 
abdomen  presents  an  area  of  flatness  with  resonance  in  the  flanks, 
from  crowding  of  the  intestines  into  the  lateral  portions  of  the  cavity. 
The  caseating  variety  is  to  be  differentiated  from  new  growths  of  the 
abdominal  viscera  by  the  facts  that  fever  usually  is  present,  and  that 
the  tumors  are,  as  a  rule,  multiple;  from  intra-abdominal  abscesses 
tuberculous  peritonitis  is  distinguished  by  the  absence  of  leukocytosis. 
When  the  diagnosis  is  in  doubt,  the  tuberculin  test,  inoculation  of  a 
guinea-pig  by  the  fluid,  or  an  exploratory  laparotomy,  may  be 
employed. 

Treatment. — Experience  has  abundantly  proved  that  in  cases  of 
the  ascitic  variety  of  tuberculous  peritonitis,  laparotomy  with  evacua- 
tion of  the  fluid  and  subsequent  suture  of  the  wound  with  or  without 
drainage,  results  in  cure  of  the  disease  in  about  50  per  cent,  of  the 
cases.  The  same  treatment  applied  to  the  caseating  form  of  the  disease, 
with  a  limited  separation  of  adhesions  and  the  evacuation  of  abscesses 
if  present,  results  in  marked  improvement  or  recovery  in  a  smaller 
number  of  instances.  The  reason  for  this  is  not  definitely  known. 
Hildebrandt,  from  a  series  of  animal  experiments,  concluded  that  the 
opening  of  the  abdomen  and  admission  of  air  resulted  in  a  more  or  less 
prolonged  hyperemia,  which  exerted  a  curative  effect  upon  the  disease. 
Other  experimenters  have  advanced  the  hypothesis  that  the  operation 
caused  the  death  of  numerous  bacilli,  and  that  these  produced  an 
antitoxin  which,  by  absorption,  acted  in  the  same  manner  as  Koch's 
tuberculin  and   other   similar  preparations. 

Yeo  and  other  medical  observers  have  reported  large  series  of  cases 
treated  by  non-surgical  measures  which  also  showed  a  recovery  rate 
of  nearly  or  quite  50  per  cent.  It  is  probable,  as  pointed  out  by 
Ochsner,  that  the  majority  of  the  cases  treated  surgically  were  more 
advanced,  and  had  resisted  treatment  by  purely  hygienic  and  medical 


518  DISEASES  OF  THE  ABDOMEN 

measures,  and,  therefore,  the  two  classes  could  not  with  propriety 
be  compared.  The  consensus  of  opinion  at  present  is  that  all  early 
cases  should  have  the  advantage  of  careful  hygienic  and  medical 
treatment  for  a  reasonable  period.  If  not  improved,  they  should  be 
treated  by  laparotomy. 

William  J.  Mayo  strongly  recommends  a  search  for  and  removal 
of  the  primary  focus,  which,  in  a  large  number  of  cases,  will  be  found 
in  the  Fallopian  tubes  or  appendix.  A  failure  to  remove  this,  in  his 
opinion,  is  responsible  for  many  cases  of  relapse. 

Chronic  Peritonitis. — This  term  covers  a  variety  of  conditions,  most 
of  which  are  of  purely  medical  interest.  Among  these  may  be  men- 
tioned :  a  general  thickening  of  the  membrane,  accompanied  by  ascites 
and  often  associated  with  cirrhosis  of  the  liver;  localized  thickening 
and  adhesions  remotely  associated  with  the  septic  forms  of  peritonitis; 
and  the  general  adhesive  variety  of  tuberculous  peritonitis  which  is 
the  result  of  recovery  from  either  of  the  two  acuter  forms  of  the  disease. 
They  are  of  surgical  interest  only  when  they  give  rise  to  intestinal 
obstruction,  and  will  be  considered  under  that  head. 

Actinomycosis  of  the  Peritoneum. — Actinomycosis  of  the  peri- 
toneum may  follow  extension  of  the  process  from  the  stomach,  cecum, 
appendix,  or  from  a  retroperitoneal  or  pelvic  focus.  The  disease 
produces  a  thickening  of  the  peritoneum  with  suppuration  similar 
to  the  caseating  form  of  tuberculous  peritonitis.  Sooner  or  later 
adjacent  structures  are  invaded  and  the  disease  slowly  advances  to 
other  organs  and  the  abdominal  wall.  When  the  latter  is  involved, 
there  occurs  a  brawny  induration,  with  a  bluish-purple  discoloration 
of  the  skin,  which  gradually  fades  in  the  periphery  of  the  lesion  to  a 
dull  slate  color.  Fistula?  form  and  are  surrounded  by  granulomatous 
tissue,  making  a  characteristic  cutaneous  lesion. 

DISEASES  OF  THE  STOMACH. 

Foreign  Bodies. — Foreign  bodies  which  have  been  swallowed  may 
lodge  in  the  stomach  or  in  any  portion  of  the  intestinal  tube.  In 
general  it  may  be  stated  that  any  body  which  passes  the  esophagus 
will  in  all  probability  pass  through  the  stomach  and  bowel,  and  event- 
ually be  expelled  by  natural  processes.  The  swallowing  of  a  foreign 
body  may  be  accidental  or  intentional ;  the  former  is  observed  mostly 
in  children;  the  latter,  in  the  insane.  A  number  of  cases  are  on  record 
where,  on  operation,  the  stomach  was  found  to  contain  scores  of  irri- 
tating foreign  substances  as  nails,  tacks,  fragments  of  broken  glass, 
pins,  pocket-knives,  etc.  Hairballs  are  not  infrequently  formed  in 
the  stomach  by  the  matting  together  of  numerous  small  masses  of 
hair  or  wool  which  have  been  swallowed.  Enteroliths  are  concretions 
formed  in  the  intestinal  canal  by  the  deposition  of  salts  around  some 
foreign  body  as  a  gallstone  or  hard  fecal  concretion.  They  may  reach 
an  enormous  size. 


DISEASES  OF  THE  STOMACH 


519 


Symptoms. — The  presence  of  a  foreign  body  in  the  stomach  may 
produce  no  symptoms  whatever;  or  it  may  give  rise  to  pain,  nausea, 
and  vomiting.  These  symptoms  are  apt  to  come  on  in  paroxysms, 
and  closely  resemble  the  gastric  crises  of  locomotor  ataxia.  If  the 
bod}'  is  lodged  in  the  small  intestine  near  the  stomach,  the  symptoms 
are  similar  to  those  of  a  foreign  body  in  the  stomach.  The  pain, 
however,  may  be  localized  somewhat  lower.  If  the  body  lies  lower 
down  in  the  small  intestine  or  in  the  colon,  there  will  be  more  or  less 
constant  localized  pain,  with  or  without  symptoms  of  intestinal 
obstruction.  Coins  and  other  metallic  bodies  often  may  be  located  by 
the  .r-rays.  The  retention  of  Murphy  buttons  after  operation  upon 
the  intestines  is  of  fairly  frequent  occurrence.     As  a  rule,  they  produce 


Fig.  267. — Acute  dilatation  of  stomach.     (Conner.) 


no  symptoms  and  the  patients  are  unaware  of  their  presence.  Occa- 
sionally symptoms  are  produced  which  necessitate  their  removal. 

Treatment. — The  treatment  of  irritating  foreign  bodies  in  the 
stomach  or  intestine  consists  in  their  removal  by  gastrotomy  or 
enterotomy. 

Acute  Gastric  Dilatation,  or  Gastromesenteric  Ileus. — Hilton  Fagge, 
in  1873,  first  described  the  symptoms  of  acute  gastric  dilatation,  but 
it  is  only  within  recent  years  that  the  condition  has  been  recognized 
as  a  postoperative  complication. 

The  chief  etiologic  factors  are  a  rapid  dilatation  of  the  stomach 
with  increased  secretion,  later  the  pressure  of  the  gastric  tumor  on 
the  movable  small  intestines,  forcing  them  downward,  and  producing 


520  DISEASES  OF  THE  ABDOMEN 

thereby  tension  on  the  root  of  the  mesentery,  which  in  turn  compresses 
the  third  portion  of  the  duodenum  against  the  spine  and  causes  more 
or  less  occlusion.  Kinking  of  the  duodenum  from  prolapse  of  the 
distended  stomach  may  also  be  a  factor  of  importance. 

As  a  result  of  the  duodenal  obstruction  the  stomach  becomes  enor- 
mously distended  with  fluid  and  gas,  and  may  occupy  the  greater  part 
of  the  abdominal  cavity  (Fig.  267).  The  primary  dilatation  of  the 
stomach  is  probably  caused  by  a  muscular  paresis  from  toxemia, 
due  to  acute  or  chronic  disease,  or  from  surgical  operation  or  shock. 
The  exciting  cause  may  be  an  indiscretion  in  diet,  or  the  ingestion 
of  food  or  water  too  soon  after  operation,  before  the  stomach  wall  has 
had  time  to  regain  its  muscular  tone. 

Conner  states  that  41  per  cent,  of  the  recorded  cases  followed 
operation. 

Symptoms. — The  symptoms  of  the  condition  in  the  order  of  their 
importance  are:  vomiting,  prostration,  and  pain;  the  signs:  distention 
of  the  abdomen,  beginning  in  the  epigastric  and  left  hypochondriac 
regions  and  extending  downward  and  to  the  right,  tenderness  over  the 
region  of  the  distension,  thirst,  hiccough,  progressive  weakness  and 
obstinate  constipation. 

The  occurrence  after  operation  of  persistent  vomiting,  a  progressive 
distension  of  the  abdomen  from  above  downward,  and  a  rapidly 
advancing  prostration  without  fever  or  other  signs  of  peritonitis, 
should  at  once  awaken  the  suspicion  of  gastric  dilatation. 

Diagnosis. — The  diagnosis  can  be  established  by  the  passage  of 
the  stomach  tube  and  the  withdrawal  of  large  quantities  of  gas  and 
a  cloudy,  greenish  fluid,  with  a  sickening  foul  odor,  but  not  feculent 
in  character. 

If  unrecognized  or  untreated  the  progress  is  rapid  toward  a  serious 
and  often  fatal  exhaustion. 

Treatment. — The  treatment  should  consist  in  regular  gastric  lavage, 
hot  stupes  to  the  abdomen,  and  the  hypodermic  use  of  strychnine 
in  large  doses. 

Gastric  and  Duodenal  Ulcer. — Gastric  and  duodenal  ulcer  have 
many  pathological  and  clinical  features  in  common.  Both  may  be 
described  as  chronic  ulcerating  lesions  which  may  involve  the  mucous 
membrane,  the  submucous  or  muscular  coats,  or  extend  through  to 
the  peritoneum;  both  have  for  their  seat  of  election  tissues  in  the 
immediate  region  of  the  pyloric  sphincter;  both  give  rise  to  a  chronic 
digestive  disorder  of  middle  life,  characterized  by  periodic  attacks  of 
epigastric  pain,  excessive  gas  and  occasional  vomiting;  both  may  be 
complicated  by  severe  hemorrhage,  perforation  or  stenosis.  On  the 
other  hand,  carcinoma  which  frequently  results  from  the  degenera- 
tion of  a  gastric  ulcer  seems  almost  never  to  take  its  origin  from  the 
duodenal  lesion. 

Regarding  frequency  it  may  be  stated  that  gastric  and  duodenal 
ulcer  occur  in  about  2  per  cent,  of  all  adult  subjects.     While  it  is 


GASTRIC   ULCER  521 

undoubtedly  true  that  spontaneous  cure  occurs  in  a  large  number  of 
instances,  in  the  majority  of  cases,  the  disease  is  progressive,  and  leads 
to  chronic  invalidism,  or  death  from  one  of  the  terminal  complications. 

GASTRIC  ULCER. 

The  disease  occurs  in  three  forms:  First,  the  mucous  erosion  or 
minute  bleeding  point,  with  difficulty  seen  at  autopsy  or  at  operation 
unless  actively  bleeding.  It  is  often  multiple  and  gives  rise  to  copious 
hemorrhages,  but  rarely  to  aggravated  symptoms  of  dyspepsia. 
Second,  the  acute  non-indurated,  round,  or  peptic  ulcer,  most  fre- 
quently observed  in  anemic  young  women  between  eighteen  and 
thirty  years  of  age.  This  often  bleeds  copiously,  gives  rise  to  acute 
pain,  pyrosis,  nausea,  and  vomiting,  and  is  generally  associated  with 
hyperchlorhydria.  Third,  the  chronic  indurated  ulcer,  involving  all 
the  coats  of  the  viscus  and  often  associated  with  a  cicatrix  on  the 
peritoneal  surface.  This  variety  occurs  with  greater  frequency  in 
men  between  thirty  and  fifty,  and  is  the  lesion  present  in  a  large 
number  of  the  patients  who  suffer  for  many  years  from  intractable 
dyspepsia. 

Etiology. — The  etiology  of  gastric  and  duodenal  ulcer  is  still  obscure, 
although  a  considerable  amount  of  research  has  been  and  is  being 
carried  out,  in  the  hope  that  when  the  causation  of  the  disease  can  be 
clearly  demonstrated,  more  rational  therapeutic  measures  may  be 
formulated  than  those  at  present  in  use. 

Undoubtedly  autodigestion  of  the  gastric  mucous  membrane,  made 
possible  by  a  necrosis  or  diminished  vitality  of  certain  limited  areas 
of  the  gastric  mucosa,  is  one  of  the  end  results  of  the  pathologic 
process,  but  what  gives  rise  to  the  necrosis  or  diminished  resistance  of 
the  tissues  has  not  been  definitely  demonstrated.  Formerly  the  areas 
of  low  resistance  were  thought  to  be  the  result  of  trauma  from  masses 
of  incompletely  masticated  food,  or  from  local  ischemia  from  thrombosis 
of  the  neighboring  vessels,  arterial  sclerosis  or  profound  anemia.  At 
present  there  seems  to  be  more  evidence  in  support  of  the  theory 
that  the  agents  which  give  rise  to  this  lowered  resistance  are  toxic 
in  origin,  and  have  a  selective  action  on  the  small  masses  or  islands 
of  lymphoid  tissue  which  are  scattered  throughout  the  mucous  mem- 
brane of  the  stomach,  but  chiefly  found  near  the  pylorus  or  along  the 
lesser  curvature. 

The  effect  of  hemorrhagins  and  mucolysins  of  toxic  origin,  may 
also  play  an  important  part  in  the  process,  the  former  by  causing  a 
destruction  of  the  endothelial  lining  of  the  terminal  bloodvessels 
giving  rise  to  local  ecchymoses,  the  latter  by  causing  an  erosion  of  the 
epithelium  of  the  mucous  membrane.  At  any  rate  clinical  observa- 
tion demonstrates  that  most  victims  of  gastric  and  duodenal  ulcer 
are  suffering  from  some  form  of  toxemia.  Occasionally  this  may  be 
traced  to  intestinal  stasis,  but  more  frequently  to  some  sub-acute  septic 


522  DISEASES  OF  THE  ABDOMEN 

focus,  as  a  chronic  appendix,  biliary  sepsis,  Rigg's  disease,  or  infection 
of  the  tonsils  or  one  of  the  nasal  sinuses.  During  a  recent  series  of 
experiments  Rosenow  was  able  to  produce  gastric  ulcer  in  dogs,  by 
injecting  cultures  of  various  strains  of  streptococci  directly  into  the 
circulation.  In  a  few  instances  these  organisms  were  demonstrated  in 
the  deeper  tissues  of  the  ulcer.  If  these  observations  can  be  confirmed, 
the  etiology  of  gastric  and  duodenal  ulcer  will  be  much  simplified,  and 
in  all  probability,  placed  upon  a  sound  bacterial  basis. 

While  the  first  and  second  varieties  may  give  rise  to  severe  and 
often  fatal  hemorrhage,  and,  while  the  round  peptic  ulcer  may  occa- 
sionally perforate,  it  is  with  the  third  easily  recognized  form  that 
the  surgeon  has  largely  to  deal. 

This  particular  type  occurs  much  more  frequently  in  the  stomach, 
and  is  more  commonly  observed  in  men.  Of  the  stomach  ulcers 
90  per  cent,  occur  at  the  pylorus  or  along  the  lesser  curvature.  Of  the 
latter  a  frequent  type  is  the  "saddle  ulcer"  extending  from  the  lesser 
curvature  downward  on  both  the  anterior  and  posterior  surfaces  of  the 
stomach.  Multiple  ulcers  are  not  infrequent,  and  a  given  ulceration 
may  pass  the  pylorus  and  involve  both  the  stomach  and  duodenal 
mucous  membranes. 

Symptoms. — The  symptoms  of  chronic  indurated  gastric  ulcer 
are  generally  those  of  an  obstinate  dyspepsia.  The  typical  symptoms 
of  ulcer  may  for  a  time  be  preceded  by  those  of  hyperchlorhydria, 
acid  eructations,  moderate  discomfort  after  meals,  and  a  hungry, 
gone  feeling  at  the  pit  of  the  stomach  before  meals,  which  is  relieved 
by  taking  food. 

When  open  ulcer  is  present  there  is  epigastric  pain,  which  appears 
regularly  from  one-half  to  two  hours  after  the  ingestion  of  food.  This 
pain  varies  from  a  dull  feeling  of  weight  to  a  severe  and  progressively 
increasing  paroxysm  of  pain  resembling  gallstone  colic.  At  the 
height  of  the  paroxysm  vomiting  may  occur,  which  gives  prompt 
relief.  The  vomited  matter  is  exceedingly  acid  and  leaves  a  burning 
sensation  in  the  throat.  Acid  eructations  and  tenderness  are  generally 
present.  Gastric  analysis  will  frequently  show  an  increase  both  in 
the  total  acidity  and  the  free  hydrochloric.  Anemia  and  loss  of  weight 
may  occur  from  inanition,  as  the  typical  sufferer  from  gastric  ulcer  will 
starve  himself  rather  than  endure  the  pain  of  taking  hearty  food. 
Hemorrhage  occurs  in  the  majority  of  cases  of  ulcer.  The  amount  is 
often  so  small  as  only  to  be  detected  by  a  careful  microscopic  examina- 
tion of  the  stools  or  delicate  chemical  tests  (occult  blood).  In  a  fair 
number  of  the  cases  the  bleeding  is  copious,  evidenced  by  severe 
hematemesis  and  well-marked  melena.  In  a  small  proportion  of  the 
patients  it  may  be  the  immediate  cause  of  death.  While  all  of  these 
symptoms  except  severe  hemorrhage  may  occur  in  purely  functional 
disorders  of  the  stomach,  the  regularity  of  their  occurrence,  day  after 
day,  at  a  definite  time  after  each  meal;  the  chronicity  of  the  disorder, 
and  the  prompt  relief  of  a  given  attack  following  vomiting,  lavage 


GASTRIC   ULCER  523 

alkalies  or,  to  a  certain  extent,  more  food,  renders  the  diagnosis 
almost  certain. 

Another  characteristic  feature  of  gastric  nicer,  is  the  fact  that 
remissions  occur,  extending  over  a  longer  or  shorter  interval,  during 
which  the  patient  may  enjoy  perfect  and  symptomless  digestion. 
These  periods  of  immunity  frequently  follow  a  vacation  or  the  sudden 
relief  of  worry  or  exhausting  mental  activity.  One  of  the  most  impor- 
tant, if  not  the  most  important  advance  which  has  occurred  in  the 
diagnosis  of  gastric  and  duodenal  lesions,  is  the  employment  of  serial 
roentgenography,  which  will  be  referred  to  again  in  the  section  on  Cancer 
of  the  Stomach. 

Of  the  complications  of  gastric  ulcer,  severe  hemorrhage  occurs  in 
about  8  per  cent,  of  the  cases.  In  a  small  proportion  of  these  death 
ensues  before  any  rational  treatment  can  be  carried  out.  Autopsies 
in  these  cases  show,  generally,  erosion  of  the  splenic  artery  or  one  of 
its  larger  branches.  Gastric  hemorrhage  is  preceded  by  a  definite 
feeling  of  nausea.  This  is  followed  by  vomiting  of  large  quantities  of 
fluid  and  clotted  blood.  Melena  follows  for  several  days.  Over  90 
per  cent,  of  these  severe  hemorrhages  cease  spontaneously. 

Perforation  occurs  in  from  12  to  20  per  cent,  of  gastric  and  duodenal 
ulcers.  In  the  majority  of  instances  the  perforation  occurs  on  the 
anterior  surface,  is  accompanied  by  extravasation  of  the  highly  acid 
gastric  contents,  and  gives  rise  to  a  rapidly  spreading  septic  peritonitis. 
In  a  small  number  of  cases  the  perforation  is  minute  and  quickly  sealed 
by  a  fibrinous  exudate,  or  the  peritonitis  is  limited  by  protecting 
adhesions. 

As  a  result  of  edema,  the  gradual  development  of  cicatricial  tissue, 
peritoneal  bands,  adhesion  to  other  organs,  pyloric  stenosis  occurs  in  a 
large  number  of  these  patients.  This  results  in  a  gradual  dilatation 
of  the  stomach,  diminished  motility,  and  fermentation,  the  symptoms 
of  which  will  be  described  in  the  next  section.  Hour-glass  stomach  is  a 
rare  complication.  Another  rare  complication  of  gastric  or  duodenal 
ulcer  after  gastrojejunostomy,  is  the  formation  of  a  peptic  ulcer  of 
the  jejunum,  at  or  just  below  the  line  of  anastomosis.  These  ulcers 
rarely  give  rise  to  much  pain,  but  often  occasion  repeated  hemorrhages, 
and  in  rare  instances  perforation  will  occur. 

Prognosis. — The  statistics  of  Greenough  and  Joslyn,  based  upon 
an  analysis  of  187  cases  of  gastric  ulcer  treated  medically  at  the  Massa- 
chusetts General  Hospital,  show  that  while  80  per  cent,  were  discharged 
as  cured  and  only  8  per  cent,  died;  subsequent  inquiry  made  several 
years  later  showed  that  only  40  per  cent,  remained  well,  and  that  20 
per  cent,  had  died  as  a  result  of  the  disease.  In  other  words,  60  per 
cent,  of  the  victims  of  chronic  gastric  ulcer  treated  medically  must 
look  forward  to  death  or  a  life  of  chronic  invalidism.  Statistics  from 
the  best  modern  surgical  clinics  show  that  the  same  class  of  cases 
treated  surgically  give  a  death  rate  of  less  than  5  per  cent,  and  upward 
of  70  per  cent,  of  permanent  cures.     The  prognosis  of  primary  hem- 


524  DISEASES  OF  THE  ABDOMEN 

atemesis  is  generally  favorable.  Repeated  hemorrhages,  however, 
constitute  a  bad  prognostic  sign.  The  prognosis  of  perforation  varies 
with  the  time  which  has  elapsed  between  the  accident  and  the  lap- 
arotomy. In  cases  under  twelve  hours  the  outlook  is  favorable; 
beyond  that  period  the  mortality  increases  with  each  hour  of  delay. 
It  is  now  pretty  generally  admitted  that  gastric  ulcer  is  one  of  the  most, 
if  not  the  most  important  cause  of  cancer,  Mayo  reporting  that 
upward  of  50  per  cent,  of  gastric  cancers  removed  at  the  Rochester 
clinic  show  unmistakable  evidence  of  having  developed  upon 
ulcer. 

Treatment. — Gastric  ulcer  without  pyloric  stenosis  or  other  complica- 
tions should  be  subjected  to  intelligent,  hygienic,  medical  and  dietetic 
treatment  for  at  least  six  weeks.  If  not  relieved  by  this  treatment, 
or  if  there  is  a  strong  tendency  to  recurrence  after  a  medical  cure, 
operation  should  be  advised. 

In  indurated  ulcer  at  or  near  the  pylorus  Rodman  advises  pylorec- 
tomy  on  account  of  the  strong  tendency  of  such  lesions  to  degenerate 
into  cancer.  Under  favorable  conditions  the  mortality  should  not  be 
much  above  that  of  gastroenterostomy,  and  the  writer  advises  it  in 
otherwise  healthy  individuals  after  a  fair  statement  of  the  risks. 
Excision  is  to  be  recommended  also  in  ulcers  located  at  a  distance  from 
the  pylorus,  when  the  operation  presents  no  serious  technical  difficul- 
ties. Gastro-enterostomy  is,  however,  the  operation  of  choice  in  the 
great  majority  of  cases  of  chronic  ulcer.  It  is  also  to  be  recommended 
in  all  cases  of  recurrent  or  persistent  hemorrhage  from  ulcer.  It 
should  also  be  performed  in  those  cases  of  perforation  where  suture 
of  the  wound  causes  stenosis,  and  in  other  cases  where  the  operation 
is  an  early  one,  before  peritonitis  has  had  time  to  develop. 

Several  theories  have  been  advanced  to  explain  the  benefit  which 
follows  gastrojejunostomy  in  these  cases:  The  first  is  that  it  results 
in  at  least  a  partial  physiological  rest  of  the  pyloric  extremity  of  the 
stomach;  second,  by  directing  the  current  of  highly  acid  chyme  through 
the  stoma,  it  prevents  the  forcible  contact  of  this  irritating  fluid  against 
the  open  surface  of  the  ulcer,  which  under  normal  conditions  is  caused 
by  vigorous  peristaltic  efforts  at  the  pyloric  antrum;  third,  by  the 
quick  emptying  of  the  stomach  both  muscular  and  chemical  irritation 
is  lessened;  and  fourth,  it  insures  a  diminution  of  the  acidity  of  the 
stomach  contents  by  the  admixture  of  bile  and  pancreatic  juice  which 
gain  entrance  through  the  artificial  opening.  It  is  probable  that  all 
of  these  factors  play  a  part  in  the  therapeutic  effect.  While  it  has  been 
shown  that  in  a  large  number  of  cases  of  ulcer  with  open  pylorus, 
the  greater  part  of  the  food  still  passed  through  that  opening  after 
gastrojejunostomy  has  been  performed,  the  result  in  the  majority 
of  these  instances  is  satisfactory,  showing  that  the  quick  emptying  of 
the  stomach  and  neutralization  of  the  acid  chyme  were  the  respon- 
sible factors  in  the  relief  of  symptoms.  Other  things  being  equal, 
however,  the  cases  of  pyloric  ulcer  with  stenosis  show  a  higher  per- 


GASTRIC   ULCER  525 

centage  of  cures  after  gastrojejunostomy,  than  ulcers  situated  at  a 
distance  from  the  pylorus,  without  stenosis. 

Duodenal  Ulcer. — Although  gastric  and  duodenal  ulcers  have  many 
features  in  common,  a  number  of  differences  in  their  pathological 
anatomy,  symptomatology,  general  behavior,  and  treatment,  renders 
a  separate  consideration  desirable. 

Duodenal  ulcer  is  of  more  frequent  occurrence  than  gastric,  the  pro- 
portion being  about  six  duodenal  to  four  gastric.  Eighty  per  cent, 
occur  in  males.  Nearly  all  (98  per  cent.)  occur  in  the  first  one  and  one- 
half  inches  of  the  duodenum.  In  a  small  number  of  instances,  a 
duodenal  ulcer  may  extend  through  the  pyloric  ring  and  involve  the 
gastric  mucosa.  Duodenal  ulcers  practically  never  degenerate  into 
carcinoma.  While  extensive  ulcerations  of  the  duodenal  mucous 
membrane,  associated  with  much  infiltration  and  a  white  peritoneal 
scar  are  occasionally  encountered  (a  type  which  closely  resembles 
the  chronic  indurated  gastric  ulcer),  a  large  number  differ  widely  from 
this,  in  that  the  ulcer  is  small,  round  or  oval,  and  associated  with  a 
limited  shot-like  induration,  with  no  external  scar  or  appearance  of 
organic  lesion.  These  lesions  are  often  overlooked  unless  the  first 
part  of  the  duodenum  is  carefully  examined  and  palpated  between 
the  thumb  and  forefinger.  Codman  has  called  attention  to  the  fact 
that  this  type  of  ulcer  is  generally  situated  so  close  to  the  pyloric 
sphincter  that  its  raw  surface  is  concealed  by  the  longitudinal  folds 
of  the  duodenal  mucous  membrane  when  the  pylorus  is  closed.  When 
the  pylorus  opens  for  the  passage  of  chyme  into  the  bowel,  the  ulcer 
is  exposed  to  the  irritation  of  this  highly  acid  fluid.  He  likens  this  type 
of  ulcer  to  the  anal  fissure,  which  is  irritated  by  the  passage  of  acrid 
substances  over  its  raw  surface  during  relaxation  of  the  sphincter. 
Like  anal  fissure  also  this  ulcer  is  subject  to  periods  of  inflammation 
when  the  pain  and  other  symptoms  are  all  exaggerated  for  several 
days  or  weeks. 

Symptoms. — The  symptoms  of  duodenal  ulcer  resemble  those  of  gas- 
tric ulcer,  in  that  the  lesion  gives  rise  to  chronic  dyspeptic  attacks  of  e 
paroxysmal  character.  Pain  is  the  most  prominent  and  characteristic 
symptom.  It  occurs  with  great  regularity,  from  two  to  five  hours  after 
taking  food,  and  continues  until  the  next  meal,  when  it  is  promptly 
relieved.  It  is  therefore  often  spoken  of  as  "hunger  pain."  The  pain 
has  the  same  character  as  that  of  gastric  ulcer.  It  varies  from  a  slight 
sense  of  discomfort  or  weight  in  the  epigastrium,  to  a  severe  colic. 
Often  it  is  associated  with  gas,  and  occasionally  sour  eructations.  Vom- 
iting is  rare,  but  occasionally  is  induced  for  the  relief  it  affords.  The 
pain  generally  can  be  relieved  by  taking  more  food  or  bicarbonate  of 
sodium,  by  vomiting  or  lavage.  Many  patients  with  duodenal  ulcer 
acquire  the  bicarbonate  of  sodium  habit.  Others  obtain  relief  by  taking 
food  at  frequent  intervals.  Those  who  follow  the  latter  plan,  often 
gain  in  weight  from  the  increased  amount  of  food  ingested,  and, 
as  described  by  Moynihan,   appear   "sleek  and  well-conditioned." 


526  DISEASES  OF   THE  ABDOMEN 

These  patients  often  keep  about  and  attend  to  their  daily  duties 
for  many  years  without  evidences  of  any  serious  deterioration  in  health, 
but  the  constantly  recurring  pain  is  apt  to  result  in  a  change  in  dis- 
position, and  they  frequently  become  sullen,  morose,  and  ill-tempered. 
Like  the  subjects  of  gastric  ulcer,  these  individuals  have  frequent 
remissions  in  which  they  believe  themselves  to  be  cured.  A  vacation 
or  sudden  relief  from  work  or  anxiety  will  often  result  in  a  rapid  and 
complete  relief  of  all  symptoms;  but  recurrences  are  common,  and  as 
a  rule,  these  patients  suffer  most  during  the  late  autumn  and  winter 
months.  Not  infrequently  all  symptoms  are  exaggerated  for  a  period 
of  several  days  or  weeks,  as  a  result  of  an  acute  inflammation  about 
the  ulcerated  area.  During  these  periods  marked  tenderness  is  present 
over  the  duodenal  region,  and  fever  and  malaise  occasionally  may 
develop.  In  rare  instances  in  the  indurated  variety  a  tumor  can  be 
felt  on  palpation.  Gastric  analysis  is  of  little  value  in  these  cases, 
although  a  moderate  hyperacidity  is  usually  present. 

As  in  gastric  ulcer  and  cancer,  serial  rontgenography  will  often 
give  positive  evidence  of  duodenal  ulceration  or  induration.  It  is 
important  to  bear  in  mind,  however,  that  the  symptoms  of  both 
gastric  and  duodenal  ulcer  may  be  mimiced  by  a  purely  functional 
disorder,  caused  by  a  reflex  hyperemia  or  irritability  of  the  gastric 
or  duodenal  mucosa,  as  a  result  of  a  chronic  irritation  from  chole- 
lithiasis, a  diseased  appendix,  or  intestinal  stasis. 

Prognosis. — In  regard  to  prognosis  it  may  be  stated  that  while 
spontaneous  cure  occurs  in  a  fair  number  if  cases,  in  the  majority, 
the  tendency  is  toward  an  exceedingly  chronic  course,  leading  often 
to  stenosis,  hemorrhage,  or  perforation. 

Stenosis  occurs  somewhat  more  frequently  than  in  gastric  ulcer. 
The  symptoms  are  identical  with  those  of  pyloric  obstruction  from 
any  other  cause. 

Hemorrhage  is  present  in  small  quantities  in  most  cases  (occult 
blood).  In  a  few  the  bleeding  is  severe,  resulting  in  hematemesis  and 
melena,  and  in  rare  instances,  an  inundating  and  rapidly  fatal  hemor- 
rhage may  occur.  In  the  latter  cases,  the  pancreaticoduodenalis 
artery  is  generally  found  to  be  eroded. 

Perforation  of  a  duodenal  ulcer  is  rather  more  frequent  than  in 
gastric  ulcer.  The  symptoms  are  the  same,  pain,  sudden  and  severe; 
vomiting,  epigastric  tenderness,  muscular  rigidity,  and  later  signs 
of  a  rapidly  advancing  peritonitis.  Occasionally  a  duodenal  perforation 
will  result  in  a  localized  abscess  from  adhesion  of  the  surrounding 
tissues.  Not  infrequently  the  early  symptoms  of  a  duodenal  perforation 
may  resemble  those  of  an  acute  fulminating  appendicitis.  Codman 
has  recently  stated  that  in  a  large  series  of  cases  admitted  to  the 
Massachusetts  General  Hospital  with  a  diagnosis  of  acute  appendicitis, 
one  in  sixteen  proved  on  operation  to  be  duodenal  perforation. 

Treatment. — All  duodenal  ulcers  resisting  a  reasonable  trial  of 
hygiene,  dietetic,  and  medical  measures,  should  be  treated  surgically. 


GASTRIC   ULCER  527 

Small  ulcers  without  stenosis  should  he  treated  by  excision  if  readily 
accessible  and  the  operation  can  be  accomplished  without  producing 
stenosis.  This  will  rarely  be  found  to  be  possible  or  practicable. 
Occasionally  small  ulcers  situated  on  the  anterior  wall  with  moderate 
stenosis  can  be  excised  in  performing  a  Finney  operation  for  pyloro- 
plasty. In  the  great  majority  of  cases,  gastrojejunostomy  is  the 
operation  of  choice,  and  in  the  majority  of  instances  will  bring  about 
a  cure.  In  ulcers  with  severe  bleeding,  in  addition  to  the  gastro- 
enterostomy, pyloric  closure  should  be  effected  by  ligation  with  a  strip 
of  fibrous  tissue  dissected  from  the  rectus  sheath,  or  by  means  of  an 
aluminum  band  passed  around  the  pylorus  and  tightly  rolled  with 
the  fingers  so  as  to  obliterate  the  lumen  without  devitalizing  the 
tissues. 

The  infolding  of  duodenal  ulcers  as  a  routine  measure  by  means  of 
Lembert  sutures  is  practiced  by  a  number  of  surgeons,  in  addition 
to  the  gastroenterostomy ;  but  the  author's  results  in  these  cases 
have  been  so  satisfactory  without  this  procedure,  that  he  hesitates 
to  advise  it  unless  some  special  indication  is  present. 

The  treatment  of  acute  hemorrhage  should  be  by  rest,  ice,  opium, 
and  starvation.  Later  rectal  feeding  for  a  time,  then  fluids  and  semi- 
solids by  the  mouth.  Repeated  hemorrhages  call  for  gastroenteros- 
tomy, with  excision  of  the  ulcer  if  practicable,  or  closure  of  the  pylorus. 

The  treatment  of  acute  perforation  should  be  early  operation,  suture 
of  the  perforation,  and  gastroenterostomy,  if  the  condition  of  the 
patient  permits. 

Pyloric  Stenosis. — Pyloric  stenosis  results  from  extensive  ulceration 
and  thickening,  from  cicatricial  contraction  of  the  orifice,  from  peri- 
pyloritis,  from  new  growths,  and  from  spasm.  Pyloric  stenosis  also 
occurs  as  a  congenital  lesion,  the  cause  of  the  obstruction  in  these  cases 
being  an  enormous  hypertrophy  of  the  circular  muscular  fibres. 
As  pyloric  stenosis  is  most  frequently  associated  with  ulcer  or  car- 
cinoma, its  early  recognition  is  of  the  greatest  importance. 

The  results  of  pyloric  obstruction  are  the  gradual  development  of 
a  dilated  stomach,  with  or  without  atony  of  its  muscular  structure; 
retardation  of  the  outward  passage  of  food  into  the  intestine;  acid 
fermentation,  and  subacute  gastritis.  The  stomach  may  reach  an 
enormous  size,  and  by  its  weight  may  drop  downward  when  the 
patient  is  erect,  so  that  the  lesser  curvature  lies  two  or  more  inches 
below  the  ensiform  cartilage  and  the  greater  curvature  may  reach 
the  symphysis  pubis  (gastroptosis). 

Symptoms. — The  symptoms  of  pyloric  stenosis  are  those  of  a  dilated 
stomach.  There  is  more  or  less  constant  epigastric  discomfort,  with 
nausea,  a  foul  tongue,  and  offensive  breath.  As  only  a  small  quantity 
of  the  food  taken  passes  into  the  intestine,  and  as  little  is  absorbed 
from  the  dilated  stomach,  the  patient  rapidly  loses  flesh  and  strength, 
the  bowels  are  constipated,  the  urine  scanty,  the  skin  dry,  and  the 
mind  apathetic.     Vomiting  is  the  most  characteristic  symptom.     It 


528  DISEASES  OF   THE  ABDOMEN 

occurs  at  irregular  intervals  and  is  often  copious;  in  severe  cases  two 
or  three  quarts  may  be  expelled.  The  vomited  matter  is  made  up 
of  a  mixture  of  partly  digested  food  suspended  in  a  foul-smelling, 
dirty  gray  fluid  containing  lactic  and  butyric  acids  and  other  products 
of  decomposition.  It  often  happens  that  food  taken  a  day  or  two 
previously  can  be  recognized  in  the  vomitus. 

In  congenital  pyloric  stenosis  the  infant  vomits  frequently  and 
shows  a  progressive  loss  of  weight.  A  small  amount  of  food  may  be 
retained,  but  if  an  ordinary  feeding  is  given,  it  is  quickly  rejected. 
The  infant  apparently  suffers  from  hunger,  cries  constantly,  and  soon 
presents  the  appearance  of  rapid  starvation.  After  a  feeding,  visible 
peristaltic  waves  may  be  seen  through  the  attenuated  abdominal 
wall.    A  palpable  tumor  is  present  in  about  one-third  of  the  cases. 

A  rare  form  of  pyloric  stenosis,  presumably  due  to  spasm  and 
associated  with  hypersecretion,  is  described  as  Reichmans  disease, 
the  symptoms  of  which  are  intermittent  attacks  of  prolonged  and 
exhausting  vomiting. 

Diagnosis. — In  the  diagnosis  of  dilatation  of  the  stomach  the  physical 
signs  are  of  great  importance.  By  inspection  the  outlines  of  the  greater 
and  lesser  curvatures  are  often  clearly  projected  upon  the  abdominal 
wall;  and  peristaltic  waves  may  be  seen  passing  from  the  fundus  to 
the  pylorus  or  in  the  reverse  direction. 

By  palpation  one  may  elicit  an  abnormal  splashing,  of  wide  extent, 
at  a  time  when  the  normal  stomach  should  be  empty.  A  dilated 
stomach  when  distended  by  gas  affords  a  uniform  elastic  resistance 
like  that  of  an  air  cushion. 

By  percussion,  in  the  erect  posture,  a  line  of  flatness  can  be  deter- 
mined, which  corresponds  to  the  level  of  fluid  in  the  dependent  part 
of  the  greater  curvature.  If  now  more  fluid  be  swallowed,  the  upper 
level  of  flatness  will  be  found  at  a  higher  plane.  If  the  patient  be  placed 
in  the  dorsal  position,  or  if  the  fluid  be  removed  by  the  tube,  the 
flatness  will  give  place  to  resonance. 

When  the  stomach-tube  is  passed  far  enough  to  be  arrested  by 
the  greater  curvature  the  length  of  tube  beyond  the  incisor  teeth 
may  reach  twenty-eight  inches  or  more;  whereas  the  length  for  a 
normal  stomach  scarcely  exceeds  twenty-four  inches.  If  the  stomach 
be  inflated  with  air,  by  means  of  the  rubber  bulb  of  an  atomizer 
attached  to  the  stomach  tube,  the  examination  by  inspection  and 
percussion  will  be  greatly  facilitated.  The  capacity  of  the  organ 
may  also  be  estimated  by  measuring  the  maximal  quantity  of  water 
which  can  be  introduced  through  the  tube  and  again  recovered  by 
immediately  siphoning  off.  Sometimes  it  is  difficult  to  distinguish 
between  dilatation  of  the  colon  and  that  of  the  stomach;  but  a  de- 
cision may  be  reached  by  distending  one  organ  with  water  and  the 
other  with  gas. 

If  the  gastric  dilatation  be  due  to  a  pyloric  carcinoma,  which  has 
not  developed  from  the  margins  of  an  older  ulcer,  it  will  generally 


GASTRIC   ULCER  rr2(.) 

be  Pound  that  free  hydrochloric  acid  is  absent  or  present  only  in  traces; 
or  that  combined  hydrochloric  acid  is  present  alone,  while  lactic  acid 
is  easily  recognizable.  Absence  of  hydrochloric  acid  with  presence 
of  lactic  acid  is  not  pathognomonic  of  carcinoma;  it  indicates  neces- 
sarily only  pyloric  obstruction,  gastric  dilatation,  stagnation  of  the 
stomach  contents,  and  secretory  inability;  but  carcinoma  of  the 
pylorus  is  by  far  the  commonest  cause  of  these  associated  conditions. 

In  addition  to  the  ordinary  chemical  tests,  it  is  well  to  search  for 
red  blood  cells  with  the  microscope  and  to  test  for  hemoglobin  chemic- 
ally. In  rare  instances  small  particles  of  carcinomatous  growth  may 
be  recognized  by  the  microscope. 

When  hydrochloric  acid  is  absent  and  lactic  acid  present,  partic- 
ularly in  cases  of  carcinoma,  there  will  often  be  found  myriads  of 
large,  slender  bacilli  which  stain  brown  with  Grain's  iodine  solution. 
These  "  Boas-Oppler"  bacilli  are  quite  suggestive  of  carcinoma. 

Treatment. — The  treatment  of  this  condition  consists  in  surgical 
procedures  which  enlarge  the  pyloric  orifice,  or  those  which,  by  estab- 
lishing a  new  outlet,  sidetrack  the  obstruction  and  allow  the  organ 
to  regain  its  normal  tone.  The  former  may  be  accomplished  by 
pyloroplasty  and  pylorectomy;  the  latter,  by  gastroenterostomy, 
soon  to  be  described.  In  congenital  stenosis,  gastroenterostomy  is 
the  method  of  choice,  although  the  mortality  is  necessarily  high. 
Bunts  recently  reported  a  series  of  69  cases  treated  by  gastroenteros- 
tomy with  a  mortality  of  53  per  cent. 

Cardiospasm. — A  rare  disease,  probably  of  nervous  origin,  giving 
rise  to  spasmodic  closure  of  the  cardiac  sphincter  and  retention  of 
food  in  the  esophagus.  If  the  spasm  continues,  a  compensatory  hyper- 
trophy of  the  muscular  coats  of  the  esophagus  occurs,  which  for  a  time 
prevents  the  development  of  other  symptoms.  Sooner  or  later, 
however,  if  the  spasm  is  not  relieved,  dilatation  of  the  esophagus 
results,  with  retention  of  food  and  regurgitation. 

Symptoms. — The  symptoms  are  at  first  only  a  choking  sensation, 
moderate  substernal  pain,  and  a  feeling  that  food  is  arrested  in  the 
gullet.  The  attacks  may  last  for  several  days  and  be  relieved  spon- 
taneously as  a  result  of  vomiting.  When  dilatation  occurs,  there  is  a 
constant  substernal  pain  and  distress  with  frequent  regurgitation  of 
undigested  food  which  is  alkaline  in  reaction.  Wasting,  thirst,  and 
scanty  urine  are  late  symptoms. 

Treatment. — The  treatment  should  consist  in  gradual  dilatation 
by  esophageal  bougies  when  this  is  possible.  If  the  bougies  are  arrested 
at  the  cardiac  orifice,  Plummer  recommends  the  swallowing  of  three 
yards  of  silk  thread,  and  later  the  passage  of  a  special  olive-pointed 
bougie  wThich  is  perforated  at  the  tip  for  the  passage  of  the  thread. 
In  other  cases  he  employs  an  ingenious  dilating  rubber  bag  attached 
to  the  end  of  a  bougie,  which  is  distended  by  water  pressure.1     In 

1  For  a  fuller  description  of  these  methods  the  reader  is  referred  to  Dr.  Plummer' s 
excellent  paper  in  the  Journal  of  the  American  Medical  Association,  May  13,  1908. 
34 


530  DISEASES  OF   THE  ABDOMEN 

neglected  cases  when  the  dilatation  has  become  permanent  and  when 
it  is  impossible  to  introduce  a  bougie  or  other  dilating  instrument, 
esophago-gastrostomy  is  to  be  recommended.  The  operation  is  both 
difficult  and  hazardous,  only  a  few  successes  have  been  recorded, 
notably  one  by  Lambert,  a  report  of  which  was  published  in  "Surgery, 
Gynecology,  and  Obstetrics"  to  which  the  reader  is  referred  for  indi- 
cations and  technic. 

Hour-glass  Stomach. — Hour-glass  stomach  is  a  cicatricial  contrac- 
tion of  the  walls  of  the  stomach  near  its  middle  which  divides  the  organ 
into  two  portions  connected  only  by  a  narrow  opening.  This  con- 
dition may  result  from  the  induration  or  healing  of  an  extensive 
ulceration,  from  perigastric  adhesions  due  to  localized  peritonitis  from 
a  small  perforation,  or  rarely  from  malignant  disease. 

If  the  obstruction  is  located  near  the  pylorus,  the  symptoms  may 
resemble  those  of  pyloric  stenosis;  if  near  the  middle  of  the  stomach, 
they  may  differ  in  that  the  patient  is  able  to  take  and  retain  only 
a  small  amount  of  food  from  the  diminished  capacity  of  the  proximal 
pouch.  Pain  is  usually  present,,  and  malnutrition  is  frequently  the 
most  important  symptom.  In  many  cases  a  tumor  can  be  felt  which 
strongly  resembles  carcinoma.  A  symptom  observed  by  the  author 
in  a  well-marked  case  was  absence  of  visible  gastric  dilatation  after 
the  introduction  of  air  through  a  stomach-tube  by  a  bulb  syringe. 
The  reason  of  this  was  apparent  on  opening  the  abdomen,  when  it  was 
found  that  the  contracting  bands  divided  the  stomach  near  its  centre, 
the  cardiac  portion,  which  would  chiefly  be  dilated  by  the  gas,  lying 
wholly  beneath  the  left  costal  arches. 

Treatment. — Three  methods  of  treating  this  condition  have  been 
suggested:  gastroplasty,  or  making  a  longitudinal  incision  though  the 
scar  and  uniting  it  transversely,  thus  enlarging  the  opening  as  in 
pyloroplasty;  gastrogastrostomy,  or  establishing  an  artificial  opening 
between  the  two  dilated  portions  of  the  stomach ;  and  gastro-enteros- 
tomy,  or  uniting  the  jejunum  with  the  cardiac  pouch. 

Peripyloritis. — Peripyloritis  is  a  condition  in  which  there  are  adhe- 
sions between  the  pylorus  and  the  anterior  abdominal  wall,  the  gall- 
bladder, the  liver,  or  the  colon,  caused  by  a  localized  peritonitis  from 
a  perforation  of  the  stomach  or  duodenum,  or  by  extension  of  an 
inflammation  from  an  infected  gall-bladder. 

Symptoms. — The  symptoms  of  peripyloritis  may  be  those  of  pyloric 
stenosis,  portal  congestion,  common  duct  obstruction,  or  simply 
localized  pain. 

Treatment. — The  treatment  is  by  laparotomy  with  separation  of  the 
adhesions  when  this  is  practicable,  but  generally  by  gastrojugenostomy. 

TUMORS  OF  THE  STOMACH. 

Carcinoma. — Next  to  the  uterus  and  female  breast,  the  stomach  is 
the  most  frequent  seat  of  carcinoma.    It  is  responsible  for  about  one 


TUMORS  OF  THE  STOMACH  531 

adult  death  in  every  sixty.  It  occurs  more  frequently  in  males  than  in 
females  the  proportion  being  nearly  three  to  one.  Of  the  pathological 
types  of  the  disease,  adenocarcinoma  is  by  far  the  most  frequent. 
In  the  Mayo  clinic  over  90  per  cent,  of  specimens  removed  were 
demonstrated  to  be  of  this  variety.  Colloid  cancer,  scirrhus  and 
epithelioma  are  occasionally  encountered.  Cancer  affects  the  pylorus 
and  lesser  curvature  in  more  than  two-thirds  of  the  cases.  It  is  rarely 
limited  to  the  anterior  or  posterior  wall  or  the  greater  curvature. 
It  is  of  fairly  frequent  occurrence  at  the  cardiac  orifice.  The  disease 
occurs  late  in  life;  an  overwhelming  majority  developing  after  the 
fortieth  year.  The  rate  of  growth  varies  considerably,  those  of  the 
fibrous  or  scirrhus  type  advance  slowly,  while  the  more  cellular 
varieties  extend  rapidly. 

Colloid  cancer  involves  all  the  coats  of  the  stomach  at  an  early 
date,  often  spreads  to  neighboring  organs  and  almost  invariably 
develops  multiple  peritoneal  metastases  with  ascites. 

Extension  of  the  disease  follows  as  a  rule,  the  lymphatic  channels; 
thus  in  pyloric  growths  and  those  along  the  lesser  curvature  the  lymph 
nodes  in  the  gastrohepatic  omentum  are  first  involved,  while  in  growths 
of  the  greater  curvature  those  lying  between  the  two  layers  of  the 
great  omentum  are  enlarged.  At  a  later  period  the  supraclavicular  and 
inguinal  lymph  nodes  rarely  are  invaded.  Direct  extension  of  the 
disease  to  the  pancreas  or  liver  is  not  infrequent,  and  occasionally 
enlargement  of  the  liver  and  other  hepatic  symptoms  are  noticed  before 
the  stomach  lesion  is  recognized. 

Symptoms — The  symptoms  of  gastric  cancer  may  for  a  long  time 
be  extremely  obscure.  In  not  a  few  instances  the  patients  present 
only  symptoms  of  general  ill  health,  with  progressive  anemia  and 
loss  of  flesh  and  strength.  In  most  cases,  however,  there  is  a  history 
of  impaired  digestion,  with  a  certain  amount  of  pain,  nausea,  and 
vomiting.  These  symptoms  occur  more  frequently  after  taking 
food,  although  the  vomiting  may  be  irregular  or  absent  in  cases  of 
cancer  limited  to  the  anterior  or  posterior  wall  of  the  organ.  In 
pyloric  cancer  the  vomiting  occurs  one  or  two  hours  after  taking 
food;  in  cancer  of  the  cardiac  orifice,  at  a  much  earlier  period.  Except 
in  the  very  cellular  varieties,  hemorrhage  is  rarely  profuse.  It  is 
frequently  present,  however,  and  appears  as  a  black  "coffee-ground" 
mass  in  the  vomited  material.  In  a  fairly  large  number  of  cases, 
where  the  disease  develops  upon  a  pre-existing  ulcer,  the  dyspeptic 
symptoms  have  existed  for  years,  and  the  early  history  is  characteristic 
of  benign  ulcer.  In  these  cases,  with  or  without  a  recent  period  of 
remission,  the  clinical  picture  gradually  changes.  The  pain,  at  first 
acute,  localized  and  paroxysmal,  changes  to  a  general  discomfort 
present  all  the  time  but  increased  after  food.  Eructations  change 
from  acid  to  foul.  Vomiting  occurs  less  regularly  and  affords  less 
relief.  The  appetite  changes  from  a  desire  to  a  loathing  of  food. 
Emaciation  develops  more  rapidly  and  there  is  a  sense  of  bodily 


532  DISEASES   OF    THE   ABDOME.\ 

weakness  and  mental  depression  out  of  proportion  to  the  lessened 

intake  of  food.  Hemorrhage  is  more  constant  Imt  often  less  in  amount. 
Anemia  advances  and  symptoms  of  malignant  cachexia  occur. 

Gastric  analysis,  in  the  later  stages,  shows  an  absence  of  free  hydro- 
chloric acid,  the  presence  of  lactic  acid,  and  the  Boas-Oppler  bacillus. 

The  presence  of  a  palpable  tumor  in  the  epigastric  region,  while 
frequently  detectable  in  the  later  stages  of  the  disease,  is  not  an 
early  sign,  for  the  reason  that  the  growth  of  the  tumor  is  slow,  and 
it  rarely  reaches  a  size  to  render  its  recognition  easy  until  other  symp- 
toms render  the  diagnosis  certain.  Moreover,  only  a  small  portion 
of  a  stomach  is  accessible  to  palpation,  as  two-thirds  or  more  of  this 
organ  lies  beneath  the  ribs  on  the  left  side.  When  felt,  the  tumor 
is  usually  hard  and  nodular,  and  moves  at  first  with  respiration.  At 
a  later  period  it  may  become  fixed  from  adhesions  to  the  deeper  parts. 
Occasionally  a  dilated  stomach  may  be  seen  on  inspection,  presenting 
peristaltic  waves  moving  from  left  to  right.  In  the  later  -tages  of  the 
disease  there  is  increased  pain,  copious  vomiting  of  a  foul-smelling 
material  containing  food  remnants,  rapid  wasting,  progressive  pros- 
tration, and  a  dry  sallow  skin.  The  stomach  finally  rejects  all  food, 
the  patient  becomes  bed-ridden  and  dies  from  hemorrhage,  starvation, 
or  exhaustion  from  profound  cachexia. 

Pyloric  cancer  produces  gastric  dilatation  with  the  characteristic 
symptoms;  cancer  of  the  cardiac  orifice  produces  atrophy  of  the 
stomach  with  enormous  dilatation  of  the  esophagus.  Cancer  involving 
the  body  of  the  organ  without  encroaching  upon  either  orifice  may 
exist  for  months  without  producing  any  characteristic  symptoms. 

Diagnosis. — Viewed  from  a  standpoint  of  surgical  treatment,  it 
is  of  the  utmost  importance  that  cancer  of  the  stomach  should  be 
recognized  at  the  earliest  possible  moment,  for  it  is  only  at  this  period 
that  radical  treatment  holds  out  any  chance  of  success.  The  occurrence 
of  dyspeptic  symptoms  with  loss  of  flesh  and  anemia  in  an  individual 
over  forty  years  of  age,  or  a  distinct  aggravation  of  a  previous  digestive 
disturbance,  should  always  awaken  the  suspicion  of  cancer.  If  to  this 
are  added  evidences  of  decreased  motility  of  the  organ,  with  an  absence 
of  free  hydrochloric  acid,  exploratory  laparotomy  for  purposes  of 
diagnosis  and  treatment  is  justifiable  if  the  patient  wishes  to  avail 
himself  of  the  advantages  of  an  early  radical  operation.  Gastric 
ulcer  generally  can  be  excluded  by  the  age  of  the  patient,  the  less 
frequent  but  more  profuse  hemorrhage,  the  more  violent  attacks  of 
pain,  hyperacidity,  and  the  fact  that  the  disease  may  last  for  many 
years  without  loss  of  weight  and  strength  and  with  periods  of  distinct 
improvement  in  the  general  nutrition  and  anemic  condition,  between 
attacks.  Atonic  gastritis  may  show  an  absence  of  hydrochloric 
acid,  the  digestive  disturbances,  the  loss  of  weight  and  strength,  the 
anemia,  but  rarely  the  cachexia.  Moreover,  the  progre>s  of  the  disease 
is  much  slower.  One  of  the  most  recent  and  most  valuable  aids  to  the 
diagnosis  of  gastric  cancer,  is  the  evidence  furnished  by  the  x-rays. 


TUMORS  OF  the  stomach  533 

Serial  gastric  rontgenography,  after  the  ingestion  of  a  bismuth  meal, 
will  often  demonstrate  stenosis,  ulcerations,  areas  of  infiltration, 
and  an  interruption  of  the  normal  peristaltic  waxes,  which,  with 
other  symptoms  and  signs,  render  an  early  diagnosis  highly  probable. 
Not  infrequently  in  the  presence  of  early  and  comparatively  unim- 
portant symptoms,  the  rontgen  rays  will  give  positive  evidence  of 
an  organic  lesion,  at  a  time  when  radical  operation,  can  offer  sanguine 
hope  of  a  cure.1 

Prognosis. — The  disease,  unless  radically  removed  at  an  early 
period,  is  invariably  fatal,  death  occurring  in  from  one  to  two  years 
after  the  first  characteristic  symptoms.  The  interest  awakened  by 
the  increasing  number  of  cures  by  early  and  radical  operative  measures, 
which  have  been  reported  during  the  past  few  years,  has  led  to  more 
careful  methods  of  examination  and  earlier  diagnosis.  As  a  result  of 
this,  many  cases  are  now  subjected  to  operation  at  a  more  favorable 
period,  and  surgeons  confidently  look  forward  to  better  statistics  in 
the  near  future.  In  late  cases  life  often  can  be  prolonged  and  suffering 
relieved  by  certain  palliative  surgical  measures,  as  gastrostomy  and 
ga  st  ro-enterost  <  >m  y . 

Treatment. — As  soon  as  the  diagnosis  is  established  or  rendered 
even  probable,  it  should  be  decided  which  method  of  treatment  is 
to  be  followed,  the  radical  or  the  palliative.  Radical  treatment  by 
early  removal  of  the  growth  is  indicated  in  the  primary  stages  of  the 
disease  before  wasting  or  marked  anemia  has  occurred,  and  when 
there  is  reason  to  believe  that  the  disease  can  be  thoroughly  eradicated. 
This,  of  course,  can  only  be  determined  by  an  exploratory  operation. 
Enlarged  lymph  nodes  may  be  due  to  septic  absorption  from  a  malig- 
nant ulcer,  and  should  not  deter  the  surgeon  from  radical  operation 
if  other  conditions  are  favorable.  Carcinoma  of  the  pylorus  should 
be  removed  by  pylorectomy.  If  the  disease  involves  the  body  of  the 
organ,  gastrectomy,  partial  or  complete,  is  indicated.  Neither  of 
these  operations  should  be  attempted  if  there  is  extensive  lymphatic 
metastasis,  adhesion  to  other  organs,  or  if  there  is  marked  anemia  or 
cachexia. 

If  the  palliative  method  of  treatment  is  to  be  followed,  the  patient 
should  be  placed  in  the  most  favorable  hygienic  surroundings,  should 
have  an  abundance  of  easily  digestible,  nourishing  food,  and  if  the 
stomach  is  irritable  or  there  is  evidence  of  diminished  motility,  with 
dilatation  and  fermentation,  lavage  should  be  practised  daily.  Gastro- 
enterostomy should  be  performed  in  cases  of  pyloric  stenosis,  gastros- 
tomy when  the  cardiac  orifice  is  involved.  The  technic  of  these 
operations  will  be  described  in  another  section. 

Sarcoma. — Sarcoma  of  the  stomach  is  a  rare  disease.  Although, 
according  to  W.  S.  Fenwick,  it  is  present  in  from  5  to  '8  per  cent,  of 

1  For  a  description  of  the  modern  method  of  serial  rontgenography  in  diseases  of  the 
stomach  and  duodenum,  the  reader  is  referred  to  an  article  by  the  author  and  Dr. 
Lewis  G.  Cole,  published  in  Annals  of  Surgery,  1915. 


534 


DISEASES  OF  THE  ABDOMEN 


all  malignant  growths  of  the  organ;  the  statistics  of  the  Mayo  Clinic 
show  in  their  large  series  of  cases,  the  ratio  to  be  considerably  below 
1  per  cent.  Two  forms  are  described,  the  small  round-cell  or  lympho- 
sarcoma, a  rapidly  growing  and  exceedingly  malignant  tumor,  and  the 
spindle-cell  variety  or  fibrosarcoma,  a  slower  developing  and  less 
malignant  growth.  The  disease  occurs  at  an  earlier  age  than  car- 
cinoma, the  majority  of  cases  developing  in  women  between  thirty 
and  forty  years  of  age.  The  disease  resembles  carcinoma  in  that  there 
are  early  digestive  disturbances,  localized  pain,  hemorrhage,  and 
vomiting,  with  rapid  loss  of  flesh  and  strength  and  progressive  anemia. 
It  differs  from  carcinoma  in  that  the  lymphosarcoma  grows  faster  and 
reaches  a  greater  size  (Fig.  208);  it  is  more  movable,  and  is  frequently 


Fig.  268. — Sarcoma  of  the  stomach. 

associated  with  enlargement  of  the  spleen,  fever,  general  purpura, 
and  the  presence  of  small  cutaneous  sarcomatous  nodules  around  the 
umbilicus.  In  lymphosarcoma  no  surgical  treatment  is  to  be  recom- 
mended, as  the  growth  progresses  rapidly  to  a  fatal  termination,  and 
when  the  disease  is  sufficiently  far  advanced  to  admit  of  a  positive 
diagnosis  it  has  passed  beyond  the  possibility  of  surgical  relief.  Fibro- 
sarcoma should  be  treated  in  the  same  manner  as  gastric  carcinoma. 


OPERATIONS  ON  THE  STOMACH. 

Gastrotomy. — Gastrotomy    consists   in    opening   the    stomach   for 
purposes  of  diagnosis,  the  removal  of  a  foreign  body  or  small  pedun- 


OPERATIONS  ON   THE  STOMACH  535 

ciliated  tumor,  or  to  effect  dilatation  of  the  pyloric  orifice.  A  median 
incision  should  be  made  about  four  inches  in  length,  beginning  at 
a  point  about  one  inch  below  the  ensiform  cartilage.  When  the 
peritoneal  cavity  is  opened,  the  stomach  is  drawn  into  the  wound 
and  the  adjacent  viscera  protected  by  the  insertion  of  several  pads 
of  gauze,  to  each  of  which  an  artery-clamp  or  metal  ring  has  been 
attached.  An  incision  is  then  made  in  the  anterior  wall  of  the  stomach 
parallel  with  its  longitudinal  axis,  and  through  this  whatever  further 
manipulations  are  necessary  are  carried  out.  The  stomach  wound  is 
then  closed  by  two  rows  of  sutures,  a  deep  one  of  catgut  including 
all  the  coats,  and  a  superficial  row  of  silk  sutures  introduced  by  the 
Lembert  or  Halsted  method.  The  abdominal  wound  can  then  be  closed 
by  layer  suture,  catgut  for  the  peritoneum,  chromicized  catgut  for  the 
muscular  and  aponeurotic  layers,  and  silk  or  silkworm  gut  for  the  skin, 
or  by  through-and-through  silkworm-gut  or  silver-wire  sutures.  The 
latter  method  in  the  upper  part  of  the  abdomen  is  thought  by  many 
surgeons  to  give  results  equally  as  good  as  the  layer  suture. 

Digital  or  Instrumental  Dilatation  of  the  Pylorus. — Digital  or  in- 
strumental dilatation  of  the  pylorus  may  be  carried  out  through  a 
gastrotomy  wound  by  the  fingers  or  by  the  use  of  a  uterine  dilator. 
The  method  is  dangerous  and  seldom  used. 

Pyloroplasty. — Withdraw  the  pylorus  through  a  median  incision  in 
the  abdominal  wall.  Make  a  longitudinal  incision  through  the  stric- 
ture. Convert  the  longitudinal  incision  into  a  transverse  opening  by 
drawing  the  edges  of  the  wound  widely  apart  by  two  blunt  retractors, 
and  unite  by  a  double  row  of  Lembert  or  Halsted  sutures. 

Finney,  of  Baltimore,  has  devised  a  new  and  satisfactory  method 
of  pyloroplasty.  He  first  frees  the  region  of  the  pylorus  from  all 
adhesions,  then  introduces  a  silk  retractor  at  the  summit  of  the  pylorus, 
another  through  the  anterior  wall  of  the  stomach  about  three  inches 
from  the  first,  and  a  third  through  the  anterior  wall  of  the  duodenum 
the  same  distance  from  the  pylorus.  By  drawing  the  first  retractor 
upward,  and  the  two  others  downward,  the  anterior  surfaces  of  the 
stomach  and  duodenum  are  brought  into  contact  and  united  by  a 
row  of  peritoneal  sutures  of  silk.  An  inverted  U-shaped  incision 
is  then  made  through  the  walls  of  the  stomach,  pylorus,  and  duodenum 
about  half  an  inch  from  the  line  of  suture.  The  adjacent  mucous  and 
muscular  coats  of  the  stomach  and  duodenum  are  then  united  by  a 
continuous  suture  of  catgut,  and  the  opening  closed  by  a  row  of  mattress 
sutures,  as  seen  in  Figs.  269  and  270.  This  operation  insures  permanent 
patency  and  good  drainage  from  the  dependent  position  of  the  stomach 
outlet. 

Pylorectomy,  or  Partial  Gastrectomy. — This  operation  is  indicated 
in  cases  of  early  carcinoma  of  the  pylorus.  As  Cuneo  has  demonstrated 
that  the  lymphatics  which  drain  the  pyloric  end  of  the  stomach  follow 
the  gastric  vessels  along  the  lesser  curvature  to  a  point  where  the 
gastric  artery  leaves  the  viscus  and  passes  downward  to  the  celiac 


536 


DISEASES  OF   THE  ABDOMEX 


axis,  and  that  the  lymph  vessels  of  the  greater  curvature  pass  toward 
the  pylorus  from  a  point  about  five  inches  to  the  left  of  the  duodenal 


Fig.  269. — Finney's  operation:    position  of  parts. 


Fig.  270. — Finney's  operation:    sutures  in  place. 

junction,    it   is   evident   that   to   remove  these   and   their   associated 
nodes  the  line  of  incision  through  the  body  of  the  stomach  must 


OPERATIONS  ON    THE  STOMACH 


537 


be  an  oblique  one  from  the  junction  of  the  gastric  artery  to  the  lesser 
curvature,  downward  to  a  point  about  five  inches  from  the  pylorus 
on  the  greater  curvature.  It  will  thus  be  seen  that  the  older  methods 
of  pylorectomy  advised  by  Billroth  and  Kocher  were  inadequate, 
in  that  they  removed  too  little  of  the  stomach  wall.  The  technic 
of  the  Mayo  operation  based  upon  these  observations  is  as  follows: 


Fig.  271. — Pylorectomy.     (Mayo.) 


A  generous  median  incision  is  made  over  the  gastric  area  and  the 
pyloric  end  of  the  stomach  withdrawn.  Four  ligatures  are  next 
placed  on  the  main  arteries— one  on  the  gastric  as  it  joints  the  lesser 
curvature,  one  on  the  pyloric,  and  two  on  the  gastric  epiploica  dextra 
at  the  points  of  excision.  The  greater  and  lesser  omenta  are  then 
ligated  and  divided  some  distance  from  the  stomach,  so  as  to  leave 
the  lymph  nodes  and  vessels  attached  to  the  portion  to  be  removed. 


538 


DISEASES  OF   THE  ABDOMEN 


The  peritoneum  is  then  protected  by  gauze  pads,  the  duodenum 
clamped  by  two  long-bladed  forceps,  divided,  and  the  cut  edges 
disinfected.  The  cluodenal  orifice  is  next  closed  by  a  purse-string 
suture  of  chromic  catgut.  Two  other  clamps  are  then  placed  across 
the  body  of  the  stomach  in  the  line  indicated  above  and  the  tissues 
divided  between  them.  After  disinfecting  the  wound  edges,  the 
gastric  opening  is  closed  with  two  layers  of  sutures  and  a  gastro- 
enterostomy performed  (Figs.  271  and  272). 


WIII.A.n  J  Mayo. 


Fig.  272. — Pylorectomy.     (Mayo.) 

Gastrectomy. — This  operation,  which  consists  in  removal  of  the 
greater  part  of  the  stomach,  may  rarely  be  indicated  for  carcinoma 
involving  the  body  of  the  organ.  The  method  is  exactly  the  same  as 
in  pylorectomy,  except  that  a  larger  area  is  removed.  It  will  rarely 
be  possible  to  unite  the  duodenum  with  the  cardiac  remnant  of  the 
organ,  and  resort  must  be  had  to  a  union  of  the  jejunum  with  the 
esophageal  extremity. 


OPERATIONS  ON   THE  STOMACH  539 

Gastrostomy. — The  following  method,  which  is  a  slight  modification 
of  Kader's  procedure,  is  the  simplest  and  safest  method  of  gastros- 
tomy, and  has  the  advantage  of  a  valve  action  which  prevents  leakage 
and  insures  rapid  spontaneous  closure  of  the  wound  when  the  necessity 
for  the  fistula  has  passed.  Through  a  vertical  abdominal  incision  just 
to  the  left  of  the  median  line  the  anterior  wall  of  the  stomach  is  drawn 
into  the  wound  and  held  by  clamps  or  a  provisional  suture.  Two 
circular  sutures  of  catgut  are  then  passed  through  the  peritoneal 
coat,  the  first  making  a  circle  half  an  inch  in  diameter,  the  second 
surrounding  the  first,  about  half  an  inch  from  it.  The  ends  of  each 
suture  are  left  long.  A  small  incision  is  then  made  with  a  scalpel 
in  the  centre  of  the  small  circle,  and  through  this  is  passed  a  No. 
26  F.  soft-rubber  catheter.  As  this  is  being  introduced,  the  first 
suture  is  tied  so  as  to  invert  the  peritoneum  along  with  the  catheter. 
The  second  suture  is  tied  while  the  catheter  is  again  pressed  inward, 
still  further  inverting  the  wall  of  the  stomach.  The  abdominal  wound 
is  then  closed  with  layer  or  through-and-through  silkworm-gut  sutures ; 
the  ones  placed  just  above  and  below  the  emerging  catheter  also  include 
the  peritoneal  coat  of  the  stomach.  The  tube  should  be  left  in  place 
five  or  six  days,  after  which  it  may  be  removed  and  introduced  only 
when  a  feeding  is  necessary.  If  the  conical  inversion  of  the  stomach- 
wall  is  sufficient,  no  leakage  will  take  place. 

Gastro-enterostomy. — This  operation  is  indicated  in  malignant  or 
benign  pyloric  stenosis,  and  in  certain  cases  of  gastric  and  duodenal 
ulcer.  Several  methods  are  in  use.  The  one  most  frequently  employed 
at  present  is  called  the  posterior  no-loop  suture  method.  The  abdomen 
is  opened  in  the  median  line  over  the  gastric  area.  The  transverse 
colon  is  withdrawn  and  held  upward.  An  opening  is  made  in  the  trans- 
verse mesocolon  through  which  the  posterior  wall  of  the  stomach  is 
drawn.  The  jejunum  is  next  picked  up  at  the  duodenojejunal  junction 
and  drawn  outward.  Two  clamps  are  then  placed  on  the  stomach 
and  jejunum,  as  seen  in  Fig.  273.  Mayo  grasps  the  stomach  wall  in 
such  a  way  that  the  line  of  anastomosis  will  be  from  above  downward 
and  to  the.  left,  when  the  stomach  is  replaced.  Moynihan  prefers  a 
perpendicular  line,  others  one  inclining  slightly  toward  the  right. 
When  the  clamps  are  in  place,  and  the  clamped  folds  of  the  stomach 
and  intestine  placed  side  by  side,  a  continuous  Gushing  suture  of  silk 
or  Pagenstecher  linen  thread  is  introduced  for  about  three  inches 
on  one  side  of  the  proposed  opening,  uniting  the  peritoneal  coats  of  the 
adjacent  viscera.  A  longitudinal  opening  is  next  made  into  the  stomach 
and  intestine  and  the  redundant  mucous  membrane  removed.  A 
second  line  of  suture  is  next  placed,  uniting  the  adjacent  cut  edges 
of  the  stomach  and  gut  and  carrying  it  completely  around  the  opening 
after  which  the  outside  peritoneal  Cushing  suture  is  completed. 
The  structures  are  then  replaced  within  the  abdomen  and  the  opening 
in  the  transverse  mesocolon  united  about  the  line  of  anastomosis. 
It  is  sometimes  desirable  to  make  an  anastomosis  on  the  anterior 


540 


DISEASES  OF   THE  ABDOMEN 


surface  of  the  stomach.  The  techiiic  differs  only  in  the  use  of  a  longer 
loop  of  jejunum,  passing  upwards  around  the  transverse  colon,  rather 
than  through  its  mesentery. 

Some  surgeons  prefer  to  employ  the  Murphy  button  for  the  anas- 
tomosis. When  this  is  employed,  the  gastric  opening  should  he  near 
the  greater  curvature  in  the  most  dependent  part  of  the  posterior 
wall.  Murphy  himself  employs  an  oblong  button,  which  insures  a 
larger  stoma. 


I  i ' ; -  273. — Stomach    and  jejunum  in  the  grasp  <>f  the  large  clamps,  made  ready  for 
suturing.     Small  forceps  still  marking  low  point  of  stomach.      (Mayo.) 

DISEASES  OF  THE  INTESTINE. 

Intestinal  Obstruction  or  Ileus. — Intestinal  obstruction,  or  ileus, 
may  occur  as  an  acute  or  chronic  condition.  It  is  a  term  applied  to 
a  stoppage  of  the  fecal  current  due  either  to  paralysis  of  the  intestinal 
muscle,  or  to  mechanical  occlusion,  partial  or  complete,  of  some 
portion  of  its  lumen.  It  is  associated  with  abdominal  pain,  vomiting 
and  distension. 

Etiology. — The  chief  cause  of  the  paralytic  type  is  peritonitis. 
Mechanical  occlusion  is  caused  most  frequently  by  bands  or  adhesions 
following  previous  operations  or  attacks  of  peritonitis,  of  the  latter. 
appendicitis  and  pelvic  inflammations  being  the  chief  causes.  It  may 
also  be  due  to  lodgment  of  intestine  in  abnormal  pockets  of  the 
omentum  or  mesentery,  in  hernial  orifices,  internal  or  external;  to  the 
lodgment  of  foreign  bodies,  or  to  twists  or  kinks  due  to  the  pressure 
of  intra-abdominal  tumors,  cysts  or  abscesses. 

Next  in  frequency  to  bands  or  adhesions  as  an  etiological  factor 
is  intussusception,  or  imagination  of  one  portion  of  the  bowel  into 
another  (Fig.  274).  This  occurs  chiefly  in  young  children.  In  these 
cases  an  important  causative  factor  seems  to  be  overactive  peri- 
stalsis, due  to  digestive  disturbances;  or,  sometimes,  to  traumata, 
such  as  falls  or  strains.     Several  varieties  are  recognized,  first,  the 


DISEASES  OF  THE  INTESTINE 


541 


ileocecal  variety  in  which  the  ileocecal  valve  forms  the  apex  of  an 
intussusception  and  drags  with  it  the  invaginated  cecum  and  ileum; 
second,  the  ileocolic  where  the  ileum  is  first  invaginated  through  the 
valve.  Other  forms  are  the  enteric,  in  which  the  lesion  is  confined 
to  the  small  intestine;  the  colic,  in  which  it  is  confined  to  the  colon. 
The  portion  of  the  gut  invaginated  is  called  the  intussusceptum. 
The  constriction  is  apt  to  be  greatest  at  the  neck  of  the  intussusception, 
increased  by  edema  and  venns  stasis,  and  it  is  here  that  gangrene  or 
perforation  most  commonly  occurs.  Sloughing  off  of  the  gangrenous 
intussusceptum,  and  spontaneous  discharge  through  the  bowel,  with 
recovery,  has  been  reported  a  number  of  times,  but  is  rare. 


*V£[^SU5 


Fig.  274. — Showing  relations  of  component  parts  of  an  intussusception. 

Volvulus,  or  rotation  of  a  loop  of  gut  on  its  mesenteric  axis,  is  respon- 
sible for  another  group  of  cases  occurring  most  frequently  in  adults  past 
middle  life,  and  in  more  than  half  the  cases  in  the  sigmoid  flexure. 

Cases  of  acute  intestinal  obstruction  are  sharply  divided  into  two 
groups;  those  due  to  simple  occlusion,  and  those  due  to  occlusion 
associated  with  strangulation,  or  interference  with  the  circulation. 

Symptoms. — The  symptoms  of  acute  intestinal  obstruction  are  pain, 
obstipation,  abdominal  distension,  and  prostration.  If  the  obstruction 
is  incomplete,  the  pain  is  colicky,  wave-like,  generally  referred  to  the 
region  of  the  umbilicus.  If  complete,  the  pain  is  more  constant,  and 
if  strangulation  is  present,  it  is  greatly  increased  in  severity.  Vomiting 
is  perhaps  the  most  characteristic  symptom.  It  consists,  first,  of 
stomach  contents;  then  bile;  and,  finally,  of  intestinal  matter.  When 
the  obstruction  is  complete,  vomiting  is  persistent.  Vomiting  of 
intestinal  contents  is  pathognomonic  of  obstruction. 

Intestinal  distension  develops  early  and  increases  steadily,  owing 
to  the  formation  of  gas  from  decomposing  intestinal  matter  con- 
fined above  the  obstructed  area.  This  process  also  develops  highly 
poisonous  substances  which  by  their  absorption  give  rise  to  the 
excessive  toxemia  and  shock  w^nch  always  accompany  this  condi- 
tion. Prostration  is  marked  and  increases  rapidly.  Its  degree  de- 
pends  upon   the   presence   or   absence  of   strangulation,  and  as  to 


542  DISEASES  OF   THE  ABDOMEN 

whether  the  obstruction  is  complete  or  incomplete  at  the  site  of 
the  stricture;  obstructions  high  in  the  small  intestine  causing 
profound  prostration  in  a  much  shorter  time  than  those  situated 
lower  down.  The  pulse  rises,  becomes  small  and  weak,  the  tem- 
perature is  normal,  or  subnormal;  cyanosis,  cold  perspiration,  and 
symptoms  of  collapse  develop  as  the  condition  progresses.  If  necrosis 
or  gangrene  of  any  part  of  the  bowel  occurs,  perforation  and  peri- 
tonitis may  develop.  Many  cases  come  to  the  surgeon  so  late  and 
so  desperately  ill  that  a  diagnosis  of  the  cause  of  the  obstruction  is 
impossible  prior  to  operation.  Certain  facts,  however,  may  suggest 
the  probable  existence  of  one  or  the  other  of  the  usual  varieties.  Thus 
a  history  of  previous  peritonitis  in  an  adult,  or  a  recent  abdominal 
section,  would  suggest  strangulation  by  a  band  of  adhesions;  a  gradu- 
ally developing  sausage-shaped  tumor  in  the  region  of  the  colon  in 
a  child  with  bloody  stools,  or  the  presence  of  a  protruding  mass  in 
the  rectum,  would  warrant  the  diagnosis  of  intussusception.  Acute 
sudden  pain  and  tenderness  in  the  left  inguinal  region  in  an  adult  with 
the  classic  symptoms  of  obstruction  would  lead  one  to  think  of  volvulus; 
while  the  presence  of  a  localized,  hard,  movable  tumor  in  the  region 
of  the  cecum  or  sigmoid  would  point  to  a  foreign  body. 

The  symptoms  of  intussusception  differ  from  those  of  other  forms  of 
obstruction.  The  onset  is  usually  sudden,  with  colicky  pain,  vomiting 
and  often  a  movement  of  the  bowels.  Pain  and  vomiting  continue, 
with  passages  of  blood-tinged  mucus  and  gas,  but  little  or  no  fecal 
matter.  Distension  is  moderate,  and  usually  a  sausage-shaped  mass 
can  be  felt  on  the  right  side  of  the  abdomen,  or  somewhere  along  the 
line  of  the  colon.  Occasionally  the  apex  of  the  intussusceptum  can 
be  felt  with  the  finger  in  the  rectum. 

Prognosis. — The  prognosis  of  acute  intestinal  obstruction  depends 
largely  upon  the  time  which  has  elapsed  before  surgical  relief  is 
obtained.  High  obstructions,  and  those  associated  with  strangulation, 
are  the  most  rapid  in  course  and  the  most  fatal.  Cases  which  have 
reached  the  stage  of  fecal  vomiting  and  chronic  prostration  are  attended 
with  a  high  mortality.  In  intussusception  the  prognosis  is  good  if  the 
condition  is  recognized  early,  and  operation  performed  before  change 
in  the  gut  necessitates  resection,  or  before  prostration  is  too  profound. 

Treatment. — This  invariably  should  be  surgical,  and  should  be 
instituted  as  soon  as  the  diagnosis  is  made.  In  case  of  suspected 
early  intussusception,  reduction  may  be  attempted  by  distension  of  the 
colon  with  gas  or  water,  but  prolonged  attempts  should  be  avoided, 
as  they  tend  only  to  weaken  the  patient,  and  render  him  less  liable  to 
bear  the  strain  of  operation.  With  early  operation  reduction  of  the 
intussusception  by  direct  manipulation  often  is  possible,  and  recovery 
is  the  rule.  If  gangrene  or  necrosis  is  present,  or  if  the  edema  or 
necrosis  present  at  the  neck  prevents  reduction  and  resection  has  to 
be  performed,  the  prognosis  is  grave. 

Clubbe  advises  a  forcible  oil  enema  after  the  patient  is  under 
the  anesthetic,  believing  that  this  aids  the  reduction  and  reduces  the 


DISEASES  OF   THE  INTESTINE  543 

number  of  cases  requiring  resection.  A  longitudinal  incision  over  the 
invaginated  mass  may  be  made  in  irreducible  cases,  resection  of  the 
mass  and  anastomosis  by  the  Maunsel's  method;  or,  the  entire  affected 
area  of  the  gut  may  be  excised. 

Kredel  and  Codman  have  recommended  enterostomy  in  irreducible 
cases,  combined  with  ligation  of  the  mesenteric  arteries  over  the 
intussusceptum,  with  a  view  to  favoring  rapid  sloughing  and  discharge 
by  the  rectum.  After  the  gangrenous  mass  is  cast  off  the  enterostomy 
wound  should  be  closed. 

In  operating  for  acute  ileus,  great  care  should  be  taken  to  prevent 
evisceration,  because  escape  of  distended  bowel  from  the  abdomen, 
with  the  attending  trauma  in  handling  and  the  great  difficulty  of 
returning  and  retaining  them  often  leads  to  a  fatal  termination.  If 
the  distension  is  great  and  the  cause  of  the  obstruction  cannot  be 
located  and  relieved,  the  choice  has  to  be  made  between  a  temporary 
enterostomy,  leaving  the  relief  of  the  mechanical  obstruction  to  a  later 
operation;  or  an  enterotomy  with  an  attempt  to  empty  the  distended 
coils  and  gain  more  room  for  operation. 

If  in  a  strangulated  loop  of  intestine  there  is  doubt  of  its  vitality 
it  may  be  drawn  out  of  the  abdomen,  suitably  protected  with  gauze, 
leaving  the  question  of  replacement  or  enterectomy,  to  be  determined 
at  a  later  period. 

In  cases  of  volvulus,  the  bowel  should  be  untwisted  and  anchored 
in  such  a  way  as  to  prevent  a  recurrence  of  the  condition.  If  the 
twisted  loop  is  gangrenous,  it  must  be  resected.  In  obstruction  due 
to  foreign  bodies  in  the  intestines,  large  impacted  gallstones,  etc., 
it  is  well,  if  possible,  to  move  the  obstructing  body  backward  into  a 
healthy  portion  of  the  gut  before  making  an  incision  for  its  removal. 

Chronic  Intestinal  Obstructio'n. — Chronic  intestinal  obstruction  is 
due  usually  to  a  gradual  narrowing  of  the  lumen  of  the  intestine, 
and  consequently  is  always  incomplete  during  the  period  of  develop- 
ment. It  may  be  due  to  stricture  resulting  from  the  healing  of 
an  ulcer,  to  the  growth  of  an  innocent  or  malignant  tumor  within 
the  lumen  of  the  bowel  or  infiltrating  its  wall;  to  outside  pressure  of 
tumors,  bands  or  adhesions,  foreign  bodies  or  impaction  of  feces. 

Symptoms. — The  symptoms  are  a  gradually  increasing  constipation, 
attacks  of  wave-like  colicky  pain  accompanied  with  more  or  less 
distension,  relieved  by  purgation.  As  the  condition  progresses, 
attacks  of  complete  obstipation,  with  pain,  distension  and  vomiting 
occur.  The  pain  often  will  commence  at  some  definite  area  in  the 
abdomen  near  the  site  of  the  obstruction,  radiating  from  there  to  other 
portions;  or  it  may  be  general,  or  variable  in  its  location  and  occurrence. 
The  attacks  already  described  sooner  or  later  terminate  in  complete 
obstruction,  with  its  attendant  symptoms,  varying  with  the  site  of 
the  obstruction,  the  majority  of  cases  of  chronic  obstruction  being 
located  in  the  large  intestine,  or  the  lower  ileum.  When  due  to  bands 
or  adhesions,  there  is  generally  the  history  of  attacks  of  peritonitis 
or  of  some  abdominal  operation.     If  due  to  strictures,  there  may  be  a 


544  DISEASES  OF   THE  ABDOMEN 

preceding'  history  of  ulceration  of  the  bowel.  Obstructions  by  large 
gallstones  are  sometimes  preceded  by  a  history  of  cholelithiasis,  but 
often  this  cannot  be  elicited. 

The  character  of  the  distension  is  sometimes  an  aid  in  locating 
the  site  of  the  obstruction,  as  a  rule  ovoid  distension  without  involve- 
ment of  the  colon  indicating  obstruction  in  the  ileum;  distention 
in  the  flanks  with  an  abdomen  relatively  flat  in  the  centre,  usually 
means  obstruction  in  the  descending  colon.  Visible  peristalsis,  and  a 
feeling  of  stiffening  of  the  bowel  due  to  rhythmic  muscular  contraction 
of  the  coils  proximal  to  the  obstruction,  are  valuable  signs  when  present. 

Loss  of  body  flesh  and  strength  and  general  failure  of  health  accom- 
pany the  progress  of  the  disease,  such  symptoms  being  generally  more 
marked  in  obstruction  due  to  malignant  disease. 

In  all  cases  of  chronic  obstruction,  digital  examination  of  the  rectum 
and  sigmoidoscopy  should  be  practiced. 

Treatment. — Except  in  eases  of  fecal  impaction,  which  should  be 
relieved  by  enema  ta,  catharsis,  and  the  mechanical  removal  of  the 
mass  from  the  rectum,  all  cases  of  chronic  intestinal  obstruction 
should  be  treated  surgically,  and,  if  possible,  before  the  symptoms 
become  urgent.  Early  exploratory  laparotomy  should  be  performed, 
if  there  is  reason  to  believe  that  mechanical  obstruction  of  the  bowel 
exists.  Whatever  the  cause  of  the  obstruction,  the  danger  of  the 
operation  is  greatly  increased  if  performed  in  the  presence  of  chronic 
distension.  In  cases  requiring  resection,  as,  for  constricting  growth 
of  the  colon,  if  such  distension  is  present  and  cannot  be  relieved 
by  medical  means,  it  is  better  to  do  a  preliminary  colostomy,  leaving 
a  resection  for  a  later  operation.  It  is  not  alone  the  added  mechanical 
difficulty  and  trauma,  but  the  fact  that  the  resistance  of  such  patients 
is  greatly  lowered  by  the  absorption  of  toxins  from  the  obstructed 
bowel,  which  always  increases  the  mortality  of  serious  operations 
performed  in  the  presence  of  distension. 

If  the  Cause  of  the  obstruction  cannot  be  definitely  removed,  short 
circuiting  around  the  obstructed  portion  may  be  feasible.  Or,  if  this 
is  impossible,  a  permanent  artificial  anus  above  the  obstruction  should 
be  made.  This  applies  only  to  obstructions  in  the  large  bowel,  as  per- 
manent artificial  anus  in  the  small  intestine  is  followed  by  emaciation 
and  marked  asthesia  as  well  as  by  excoriation  of  the  surrounding  skin 
from  the  irritating  character  of  the  contents  of  the  small  intestine. 

Ulcers  of  the  Bowel. — Ulcers  of  the  bowel  below  the  duodenum  may 
be  caused  by  typhoid  fever,  dysentery,  tuberculosis,  syphilis,  actino- 
mycosis, intestinal  obstruction,  or  by  the  presence  of  foreign  bodies, 
enteroliths,  or  fecal  concretions.  These  rarely  come  under  the  care 
of  the  surgeon  unless  perforation  occurs. 

Typhoid  Perforation. — Typhoid  perforation  of  the  intestine  occurs 
in  a  considerable  number  of  cases,  about  one-third  of  the  deaths  being 
due  to  this  complication.  According  to  Haggard's  statistics,  it  occurs 
most  frequently  in  the  third  week  of  the  disease,  although  cases  have 
been  reported  as  early  as  the  first  and  as  late  as  the  fourteenth  week. 


DISEASES  OF  Till':  INTESTINE  545 

In  over  !).">  per  cent,  of  the  cases  the  lesion  occurs  in  the  ileum,  generally 
within  eighteen  inches  of  the  cecum.  The  lesion  is  usually  single,  and 
generally  is  found  to  be  a  small  pinpoint  perforation  on  the  surface 
opposite  the  mesenteric  attachment.  Occasionally  several  perforations 
are  present.  The  perforation  usually  is  surrounded  by  an  infiltrated 
area  which  is  exceedingly  friable,  and  this  condition  frequently  renders 
closure  by  sutures  difficult. 

Symptoms. — The  symptoms  of  perforation  in  typhoid  fever  are 
often  obscure,  and  are  masked  by  the  symptoms  peculiar  to  the  dis- 
ease. The  evidences  at  first  are  those  of  peritoneal  irritation,  pain, 
tenderness,  and  muscular  rigidity.  The  development  of  even  a  slight 
degree  of  localized  tenderness  and  muscular  rigidity  during  the  course 
of  a  typhoid,  especially  when  following  a  sharp  increase  in  abdominal 
pain,  should  be  regarded  as  definite  warning  that  a  perforation  has 
occurred,  or  is  impending.  At  a  later  period  the  symptoms  are  those 
of  a  spreading  peritonitis,  pain,  vomiting,  increased  tenderness  and 
rigidity,  meteorism,  and  a  rapidly  progressive  prostration.  Leukocy- 
tosis may  be  an  early  symptom,  and  is  generally  present  after  peritonitis 
develops.  The  presence  of  free  fluid  and  gas  in  the  peritoneal  cavity 
is  conclusive  evidence  of  perforation,  but  these  signs  are  rarely  observed 
in  the  early  stage.  A  sudden  fall  in  the  temperature  and  rise  in  the 
pulse  rate  is  significant,  and  when  combined  with  symptoms  of  peri- 
toneal irritation  is  strong  confirmatory  evidence  of  a  perforative  lesion. 

Prognosis. — The  prognosis  in  untreated  cases  is  exceedingly  bad, 
the  death-rate,  according  to  Murchison,  being  from  90  to  95  per 
cent.  By  timely  operation  from  25  to  30  per  cent,  of  the  cases  can 
be  saved. 

Treatment. — While  the  condition  of  a  typhoid  patient  with  perfora- 
tion of  the  intestine  is  always  such  as  to  render  any  surgical  operation 
extremely  hazardous,  immediate  laparotomy,  closure  of  the  intestinal 
wound,  and  cleansing  the  peritoneal  cavity,  are  positively  indicated 
in  all  cases  seen  sufficiently  early,  and  in  which,  the  physical  condition 
is  not  so  grave  as  to  contra-indicate  the  administration  of  an  anesthetic. 
A  thorough  operation  performed  with  the  maximum  of  speed  and  the 
minimum  of  anesthesia  and  exposure,  combined  with  the  judicious 
use  of  stimulants,  especially  the  intravenous  infusion  of  saline  solution, 
will  occasionally  save  a  patient  even  under  conditions  which  seem 
most  unfavorable.  In  rare  instances  it  may  be  advisable  to  employ 
local  or  spinal  anesthesia. 

Dysenteric  Ulcerations. — Dysenteric  ulcerations  of  the  large  intestine 
rarely  perforate,  but  they  frequently  prove  fatal  by  the  exhausting 
diarrhea  and  hemorrhage  which  they  provoke,  as  well  as  by  the  hepatic 
suppuration  which  sometimes  follow  s. 

Treatment. — After    all    reasonable    medical    measures    have    been 
tried,  a  right-sided  colostomy,  with  frequent  irrigation  and  rest  of 
the  colon,  may  bring  about  cure.     Complete  extirpation  of  the  colon 
has  been  performed  with  success  in  a  few  of  these  cases. 
35 


546  DISEASES  OF  THE  ABDOMEN 

Tuberculosis  of  the  Gastro-intestinal  Tract. — Gastric  Tuberculosis. — 
Tuberculosis  of  the  stomach  is  an  exceedingly  rare  disease.  It  is 
generally  associated  with  tuberculosis  of  the  lungs  and  other  organs. 

Symptoms. — The  symptoms  are  those  of  chronic  ulcer,  and  the 
diagnosis  is  established  by  the  demonstration  of  tubercle  bacilli  in 
the  stomach  contents. 

Tuberculous  ulceration  of  the  bowel  is  of  more  frequent  occurrence 
than  that  of  the  stomach,  but  it  is  generally  secondary  to  tuberculosis 
elsewhere,  and  belongs  rather  to  the  domain  of  internal  medicine. 

Ileocecal  Tuberculosis. — Hartman  and  Pilliet,  in  1891,  called  attention 
to  a  form  of  hyperplastic  tuberculosis  of  the  intestine  resulting  often 
in  tumor  formation  and  stenosis.  While  this  condition  may  occur  in 
any  part  of  the  small  or  large  intestine,  in  over  80  per  cent,  of  the 
cases  it  involves  the  ileocecal  region.  In  these  cases  there  is  a  diffuse 
infiltration  of  the  cecal  wall,  which  generally  extends  to  the  ileum  and 
appendix.  The  mass  grows  slowly,  often  without  symptoms  at  first, 
and  not  infrequently  is  mistaken  for  a  neoplasm. 

Symptoms. — The  symptoms  of  ileocecal  tuberculosis  are,  in  the 
beginning,  those  of  an  indefinite  digestive  disorder;  moderate  pain 
and  tenderness,  diarrhea,  and  loss  of  appetite  and  weight.  Later, 
as  stenosis  develops,  the  pain  is  of  a  colicky  character  and  is  often 
referred  to  the  umbilical  region.  Still  later,  pain  and  tenderness  in  the 
right  iliac  fossa  suggest  the  diagnosis  of  chronic  appendicitis.  ^Yhen  a 
palpable  tumor  is  present,  carcinoma  or  sarcoma  often  is  suspected. 

The  disease  occurs  most  frequently  in  individuals  between  twenty  and 
forty  years  of  age.   In  doubtful  cases  the  tuberculin  reaction  is  of  value. 

Treatment. — As  the  disease  produces  stenosis  in  the  majority  of 
instances,  complete  extirpation  of  the  diseased  area  is  to  be  advised. 
This,  in  most  cases,  is  best  accomplished  by  a  two-stage  operation: 
the  first  consisting  of  an  ileocolostomy;  the  second,  an  extirpation  of 
the  diseased  area.  The  mortality  of  the  operation  carried  out  in  this 
manner,  in  suitable  cases,  is  not  over  12  per  cent. 

Actinomycosis  of  the  Intestine. — As  stated  elsewhere,  in  about  50 
per  cent,  of  the  cases  of  intestinal  actinomycosis,  the  lesion  is  located 
in  the  ileocecal  region.  The  disease  resembles,  in  its  early  stages,  the 
hyperplastic  type  of  tuberculosis.  There  is  a  massive  infiltration  of 
the  intestinal  wall,  which  later  extends  to  the  abdominal  parietes, 
producing  a  brawny  induration,  with  fistula?. 

The  discharge  is  generally  thin  and  watery,  may  be  purulent  from 
mixed  infection,  and  contains  the  characteristic  lemon-yellow  granules. 

Treatment. — The  treatment  of  this  condition  should  be  by  hygiene, 
opening  and  draining  suppurating  foci,  and  the  exhibition  of  potassium 
iodide  and  the  salts  of  copper.  If  the  diagnosis  of  the  primary  focus 
could  be  made  sufficiently  early,  radical  removal  would,  of  course, 
constitute  the  ideal  treatment. 

Diseases  Caused  by  Congenital  or  Acquired  Diverticula  of  the 
Intestine. — Intestinal  diverticula,  as  is  well  known,  are  divided  into 
t  wo  jf  general   classes — the  congenital  and  the  acquired.     The  most 


DISEASES  OF  THE  INTESTINE  547 

frequently  observed  type  of  the  congenital  variety  is  the  one  known 
as  Meckel's  diverticulum.  As  recently  described  by  Leon  Cahier, 
in  his  admirable  essay  upon  the  subject,  a  Meckel's  diverticulum 
possesses  the  following  characteristics:  "It  is  single;  it  has  a  rectangu- 
lar implantation  into  the  free  border  of  the  terminal  portion  of  the 
ileum,  generally  in  the  neighborhood  of  the  ileocecal  valve;  it  is  made 


Fig.  275. — Acquired  diverticula  of  sigmoid. 

up  of  all  of  the  coats  of  the  intestine;  it  is  generally  more  than  2  cm. 
in  length ;  and  it  has  a  terminal  filament  which  may  be  free  or  attached 
to  the  abdominal  wall,  the  mesentery,  or  another  part  of  the  intestine." 
The  acquired  diverticula,  on  the  other  hand,  are,  as  a  rule,  multiple, 
small,  thin  walled,  and  round  or  ovoid  in  shape.  They  may  be 
found  in  any  part  of  the  intestinal  canal,  but  are  more  frequent  in 


548 


DISEASES  OF   THE  ABDOMEN 


the  left  colon  and  the  rectum,  and  are,  in  reality,  hernial  protrusions 
of  the  mucous  membrane  through  the  separated  fibres  of  the  muscular 
coat  (Fig.  275). 

Acute  Diverticulitis. — An  acute  inflammation  of  Meckel's  diverticu- 
lum may  simulate  an  acute  appendicitis  so  accurately  that  a  differential 
diagnosis  is  not  possible.  The  writer  recently  operated  upon  such 
a  case,  and  on  opening  the  abdomen  found  the  diverticulum,  acutely 
inflamed,  lying  in  the  right  iliac  fossa.  In  appearance  and  size  it  so 
closely  resembled  an  inflamed  appendix  that  the  true  nature  of  the  condi- 
tion was  not  recognized  until  its  relation  to  the  ileum  was  demonstrated. 


Fig.  276. — Acute  diverticulitis  of  sigmoid. 


Treatment. — The  treatment  in  these  cases  should  be  removal  of 
the  diverticulum  when  this  is  possible  and  closure  of  the  iliac  wound 
by  Lembert  sutures.  When  this  is  not  practicable,  either  from  the 
size  of  the  junction  or  from  the  presence  of  gangrene,  intestinal  resection 
is  to  be  recommended. 

Acute  Diverticulitis  of  the  Sigmoid. — Acute  diverticulitis  of  the 
sigmoid  or  colon  has  only  recently  been  recognized  as  a  distinct  surgical 
disease.  In  1907  the  author  reported  to  the  American  Surgical  Asm>- 
ciation  a  series  of  cases  of  left-sided  intra-abdominal  infection,  in  two 
of  which  the  cause  of  the  symptoms  was  proved  to  be  the  rupture  of  an 
acquired  diverticulum  of  the  sigmoid. 


DISEASES  OF  THE  INTESTINE  549 

Symptoms. — The  symptoms  of  acute  diverticulitis  of  the  sigmoid 
are  pain,  tenderness,  and  muscular  rigidity  in  the  left  iliac  region. 
Fever  quickly  follows  these  initial  symptoms,  and  leukocytosis  is 
generally  present.  If  rupture  occurs,  symptoms  of  spreading  peri- 
tonitis may  quickly  develop,  or  if  the  process  is  limited  by  adhesions 
the  signs  of  an  intra-  or  extra-abdominal  abscess  will  appear. 

The  clinical  history  of  these  cases  so  closely  resembles  that  of 
acute  appendicitis  that  one  instinctively  thinks  of  a  transposition 
of  the  viscera.  Fig.  27(5  represents  the  condition  found  at  operation 
in  a  case  reported  by  the  writer  to  the  surgical  section  of  the  American 
Medical  Association  in  June,  1908. 

Treatment. — Regarding  the  treatment  of  this  condition  it  may 
be  stated  that  sufficient  data  are  not  available  to  enable  one  to  deter- 
mine what  percentage  of  inflamed  diverticula  actually  perforate,  and  it 
is,  therefore,  not.  possible  to  state  dogmatically  whether  a  given  case 
of  acute  diverticulitis  with  comparatively  mild  symptoms  should  be 
subjected  to  immediate  operation  or  should  be  treated  more  conser- 
servatively.  In  the  writer's  opinion,  however,  the  clinical  course  of 
the  disease  is  so  similar  to  the  various  forms  of  acute  appendicitis  that 
the  treatment  should  be  the  same.  Certainly  in  all  acute  cases  with 
severe  and  progressive  symptoms  safety  lies  in  early  operation.  If  the 
diverticulum  is  small  or  attached  to  the  bowel  by  a  narrow  pedicle, 
removal  with  closure  of  the  intestinal  wound  by  a  purse-string  or 
several  Lembert  sutures  would  be  indicated,  provided  the  surrounding 
intestinal  wall  was  not  too  much  infiltrated.  In  the  event  of  the 
diverticulum  being  large,  attached  by  a  broad  base,  or  covered  by  a 
plexus  of  enlarged  vessels,  the  safest  method  would  be  to  deliver  the 
affected  loop  of  intestine  through  the  abdominal  wound  and  treat 
it  temporarily  as  an  extraperitoneal  lesion.  If  the  situation  of  the 
lesion  is  such  that  extraperitoneal  treatment  cannot  be  carried  out, 
packing  with  gauze  from  the  abdominal  wound  to  the  lesion  is  to  be 
advised,  leaving  this  packing  in  place  from  forty-eight  to  seventy-two 
hours,  or  until  firm  adhesions  have  formed  around  the  gauze  column; 
then  removal  of  the  gauze  and  free  opening  of  the  abscess,  allowing 
it  to  drain  through  the  channel  thus  formed. 

If  rupture  has  already  occurred,  the  intestinal  wound  should  be 
united  by  suture,  if  this  is  possible;  if  not,  adequate  drainage  should 
be  provided. 

In  the  treatment  of  spreading  peritonitis  or  intra-abdominal  abscess 
from  this  cause  the  same  principles  should  be  followed  as  in  other 
abdominal  conditions. 

Chronic  Diverticulitis  of  the  Sigmoid. — William  J.  Mayo  recently 
called  attention  to  a  chronic  form  of  acquired  diverticulitis  of  the 
sigmoid,  which,  in  its  clinical  history  and  gross  appearances  at 
operation,  strongly  resembles  carcinoma. 

The  disease  usually  occurs  at  the  cancer  age,  and  gives  rise  to  a 
slowly  progressive  stenosis  with  tumor  formation. 


550  DISEASES  OF  THE  ABDOMEN 

Excision  of  the  diseased  area  is  indicated  in  those  cases  in  which 
mechanical  obstruction  exists  or  is  imminent. 

Obstruction  or  Strangulation  of  the  Bowel. — Obstruction  or  strangula- 
tion of  the  bowel  not  infrequently  occurs  as  a  result  of  a  loop  of  intestine 
being  incarcerated  under  a  Meckel's  diverticulum,  the  distal  extremity 
of  which  is  attached  to  the  mesentery  or  abdominal  wall.  The  symp- 
toms and  treatment  of  this  condition  are  considered  in  the  section  on 
Intestinal  Obstruction. 

TUMORS  OF  THE  INTESTINE. 

Tumors  of  the  intestine,  as  in  other  regions,  are  divided  into  two 
general  classes,  the  innocent  and  the  malignant.  Of  the  innocent 
tumors,  fibromata,  myomata,  adenomata,  lipomata,  and  cysts  are 
described  by  Maylard1  as  occurring  in  the  small  intestine;  and  papillo- 


Fig.  277. — -A  carcinoma  of  the  sigmoid,   causing  total  obstruction.      (Drawn  from  a 
specimen  removed  by  Dr.  W.  T.  Bull.) 

mata,  adenomata,  fibromata,  and  lipomata  in  the  large  bowel.  Car- 
cinomata  and  sarcomata  occur  in  all  parts  of  the  canal,  the  former 
being  more  common  in  the  large,  the  latter  in  the  small  intestine. 

As  a  rule,  the  non-malignant  tumors  grow  slowly  and  give  rise  to 
no  disturbance  until  they  attain  a  sufficient  size  to  produce  obstruction. 
The  fibromata,  myomata,  and  adenomata  generally  form  polypoid 
masses;  the  lipomata  arise  from  the  submucous  tissue  and  may  be 
multiple.  All  of  these  conditions  are  rare.  An  intestinal  polypus 
not  infrequently  induces  intussusception.  In  such  cases  the  tumor 
is  often  found  at  the  apex  of  the  projecting  mass. 

Cysts  of  the  intestine  or  mesentery  are  rare,  but  form  an  interesting 
group  on  account  of  their  etiology.  Dowd  believes  most  of  them  to  be 
of  embryonic  origin.     They  vary  in  size  greatly,  may  contain  a  clear 

1  The  Surgery  of  the  Alimentary  Canal. 


TUMORS  OF  THE  INTESTINE  551 

serous  fluid  or  chyle.  They  rarely  give  rise  to  symptoms  calling  for 
surgical  intervention. 

Carcinoma  of  the  large  intestine  is  generally  of  the  columnar  cell 
variety.  The  tumor,  as  a  rule,  grows  around  the  gut  and  forms  a 
constriction  similar  to  that  which  would  be  produced  by  tying  a  piece 
of  twine  about  it  (Fig.  277).  In  other  cases  the  growth  infiltrates  the 
walls,  almost  invariably  grows  concentrically  and  produces  stenosis. 
If  extremely  cellular,  it  is  often  described  as  medullary  or  encephaloid 
cancer;  if  fibrous,  as  scirrhous.  It  may  undergo  colloid  degeneration 
and  spread  rapidly  to  other  abdominal  organs. 

Sarcoma  occurs  as  a  polypoid  growth,  projecting  within  the  canal 
or  as  a  rapidly  infiltrating  tumor  thickening  the  walls  of  the  canal, 
growing  eccentrically  and  producing  dilatation.  The  first  form  is 
usually  of  the  spindle-cell  variety;  the  second,  the  round-cell  or  lympho- 
sarcoma. Both  varieties  arise  from  the  submucous  layer.  Lympho- 
sarcoma of  the  small  intestine  may  occur  in  any  part.  It  grows  with 
great  rapidity  and  extends  to  the  surrounding  peritoneum.  It  may 
occur  at  any  age,  but  is  rare  after  forty.  Carcinoma,  on  the  other 
hand,  is  more  common  after  forty,  although  Lib  man  states  that  not 
infrequently  it  has  been  reported  in  individuals  between  fifteen  and 
twenty-five,  and  has  been  observed  as  a  congenital  affection. 

Symptoms. — Growths  of  the  duodenum  are  exceedingly  rare.  When 
sufficiently  developed,  they  produce  symptoms  of  obstruction.  If 
situated  high  up,  the  obstruction  resembles  that  of  pyloric  stenosis. 
If  lower  down,  there  may  be,  in  addition,  obstruction  of  the  common 
bile  duct  and  ca.nal  of  Wirsung.  In  these  cases  the  patients  rapidly 
emaciate,  and  jaundice  and  vomiting  are  prominent  symptoms. 

Innocent  tumors  in  the  small  intestine  situated  below  the  duodenum 
rarely  give  rise  to  symptoms  unless  they  act  as  the  exciting  cause  of  an 
intussusception  or  other  forms  of  obstruction. 

Papillomata  of  the  large  intestine  may  give  rise  to  hemorrhages. 
Maylard  cites  two  cases  in  which  large  numbers  of  these  tumor 
were  found  in  the  colon,  in  one  of  which  carcinomatous  degeneration 
had  occurred  at  one  point  and  transitional  forms  at  several  others. 
The  symptoms  were  localized  pain  and  the  passage  of  mucus  and  blood. 

In  carcinoma  of  the  small  intestine  the  symptoms  are  those  of  a 
progressive  chronic  obstruction  coupled  with  rapid  loss  of  weight 
and  strength  and  anemia.  Vomiting  is  more  frequent  and  occurs 
earlier  than  in  carcinoma  of  the  large  intestine.  The  tumor  can 
rarely  be  detected  until  the  symptoms  of  obstruction  are  manifest. 

In  Carcinoma  of  the  Large  Intestine  the  symptoms  depend  upon  the 
type  of  growth :  if  of  the  constricting  form — the  most  common  type — 
there  is  gradually  increasing  constipation  merging  into  attacks  of 
obstipation;  pain,  which  may  be  a  dull  aching  at  or  near  the  site 
of  the  growth,  becomes,  as  obstruction  increases,  wave-like,  colicky, 
intermittent  in  character,  and  due  to  the  obstruction. 

Abdominal   distension  follows  later  and  often  is  accompanied  by 


552  DISEASES  OF  THE  ABDOMEN 

visible  peristalsis,  or  the  feeling  of  "stiffening"  of  the  bowel  above  the 
site  of  the  obstruction. 

Hemorrhage  may  occur,  but  is  often  absent  or  slight  in  amount  in 
the  constricting  type. 

Constitutional  symptoms  are  loss  of  weight,  loss  of  strength,  and 
general  cachexia.  If  the  growth  is  of  the  infiltrating,  non-constricting 
type,  hemorrhage  is  apt  to  be  an  early  symptom,  with  pain  in  the  region 
of  the  growth  but  not  the  colicky  pain  of  obstruction.  Diarrhea,  with 
blood  and  mucus  in  the  stools  may  be  the  first  indication  of  the  trouble 
if  located  in  the  right  colon  and  later,  alarming  hemorrhage  may  come 
from  the  ulcerated  surfaces. 

Tumor  may  be  felt  in  either  type,  or  may  be  absent,  especially  in 
the  constricting  form,  and  in  those  situated  low  in  the  splenic  flexure 
or  in  other  inaccessible  sites. 

In  sarcoma  of  the  small  intestine  the  symptoms  may  at  first  be 
extremely  obscure.  The  growth  of  the  tumor  is  usually  rapid,  and 
in  the  majority  of  cases  no  obstruction  exists.  In  many  cases  the 
symptoms  are  those  of  an  acute  intra-abdominal  inflammation: 
localized  pain,  tenderness,  muscular  spasm,  and  the  presence  of  a 
large  indurated  mass  resembling  an  inflammatory  exudate.  Fe\er 
may  be  present,  which  still  further  obscures  the  diagnosis.  Lil  n  an 
reports  that  of  5  cases  of  sarcoma  of  the  small  intestine  admitted 
to  the  Mount  Sinai  Hospital,  in  two  years,  3  were  sent  in  with  a 
diagnosis  of  acute  appendicitis.  Sarcoma  of  the  large  intestine  is 
exceedingly  rare.     It  occurs  generally  in  the  cecum. 

Ulceration  of  malignant  growths  of  the  intestine  is  of  frequent 
occurrence  in  the  later  stages;  and  perforation  may  occur,  gi\  ing 
rise  to  a  localized  or  spreading  peritonitis,  or  to  an  intra-  or  extra- 
peritoneal abscess. 

Tuberculosis  or  syphilis  of  the  intestine  may  occasionally  give  rise 
to  tumors  which  closely  resemble  carcinomata  or  sarcomata.  The 
former  condition  is  described  as  hyperplastic  intestinal  tuberculosis; 
in  the  latter  condition  the  lesions  are  generally  gummatous  in  character, 
and  may  extend  into  the  mesentery.  Accurate  diagnosis  from  gross 
appearance  is  often  impossible. 

Treatment. — Innocent  tumors  of  the  intestine  rarely  come  under 
the  care  of  the  surgeon  unless  they  produce  obstruction  or  hemorrhage. 
They  are,  however,  occasionally  encountered  in  operations  for  intestinal 
obstruction,  and  should  be  removed  by  enterotomy  or  resection  of  a 
portion  of  the  bowel. 

Treatment  of  Malignant  Tumors  of  the  Intestine. — If  the  growths  are 
adherent  to  surrounding  structure,  have  formed  secondary  deposits 
in  the  liver  or  retroperitoneal  lymph  nodes,  or  have  infiltrated  surround- 
ing tissues,  they  are  inoperable  and  can  be  treated  only  by  palliation. 
This  may  consist  in  laxatives,  enemata  or  irrigations  to  keep  the  bowels 
open;  tonics,  nourishing  food  and  sedatives,  as  needed  for  the  pain. 
Or,  if  obstruction  is  present,  colostomy  may  be  performed  above  the 


OPERATIONS  ON   THE   INTESTINE  553 

growth,  or  short  circuiting  by  anastomosis  between  proximal  and  distal 
loops.     These  means  may  prolong  life  and  lessen  the  suffering  for  some 

months,  as  many  of  the  growths  arc  relatively  slow  in  progress. 

Radical  Treatment  consists  in  the  removal  of  the  growth  with  a 
sufficient  length  of  intestine  to  get  well  beyond  the  disease.  In  tumors 
situated  in  the  large  intestine  above  the  rectum  excellent  results  may 
be  obtained  by  radical  excision,  as  anatomically  it  is  not  difficult  to 
remove  sufficient  adjacent  tissue  and  neighboring  lymph  nodes.  The 
growths  are  often  relatively  slow  in  type,  and  late  in  forming  lymph 
node  metastasis.  Enlarged  glands  in  the  neighborhood  of  the  growth 
are  not  alone  contra-indieation  to  radical  operation  for  they  have 
been  proved  in  many  instances  to  be  inflammatory  and  not  neoplastic. 

The  result-  of  excision  of  malignant  growths  of  the  rectum  are  much 
less  satisfactory.  Malignant  growths  of  the  small  intestine  are  rare, 
and  should  be  treated  on  the  same  general  principles. 

In  Sarcoma  of  the  Intestine,  the  outlook  is  much  less  favorable  unless 
it  be  of  the  polypoid  type.  Libman  was  unable  to  find  a  case  in  liter- 
ature that  had  passed  the  third  year  limit. 

Operation  for  radical  removal  of  intestinal  growths  should  never  be 
undertaken  in  the  presence  of  ileus  or  obstruction,  as  it  adds  greatly 
to  the  mortality.  If  it  is  impossible  to  relieve  distension  by  enemata 
or  medical  means  prior  to  operation,  a  preliminary  colostomy  or 
enterostomy  should  be  performed,  followed  later  by  radical  operation. 


OPERATIONS  ON  THE  INTESTINE. 

All  operations  on  the  upper  bowel  should  be  preceded  by  careful 
frequent  disinfection  of  the  oral  cavity,  stomach  lavage,  and  the 
ingestion  of  only  sterilized  food  and  water  for  thirty-six  hours  before 
the  proposed  operation. 

Enterotomy. — Enterotomy  is  an  incision  into  the  large  or  small 
intestine  for  purposes  of  diagnosis  or  for  the  removal  of  tumors  or 
foreign  bodies.  The  abdomen  is  opened  and  the  bowel  drawn  into 
the  wound,  the  peritoneal  cavity  being  protected  by  gauze  pads, 
the  incision  into  the  bowel  should  be  made  in  a  longitudinal  direction, 
and  closed  with  the  Lembert  or  Halsted  suture. 

Enterectomy. — Enterectomy,  or  removal  of  a  section  of  the  intestine 
is  indicated  for  the  extirpation  of  a  new  growth  or  stricture,  the  cure  of 
an  obstinate  fecal  fistula,  or  in  the  treatment  of  extensive  wounds 
or  gangrene  of  the  gut.  If  the  portion  to  be  removed  is  movable 
and  has  a  mesentery,  it  is  drawn  outward  through  an  abdominal 
incision,  the  peritoneum  carefully  protected  with  gauze  pads,  and 
the  lumen  of  the  bowel  above  and  below  the  diseased  or  injured  area 
closed  by  clamps  or  gauze  ligature.  A  V-shaped  incision  is  then 
made,  including  the  intestine  and  a  portion  of  the  mesentery,  the 
vessels  ligated,   and    the   mucous   edges   disinfected   with   hydrogen 


554  DISEASES  OF  THE  ABDOMEN 

peroxide  or  bichloride  solution.    The  two  ends  may  then  be  united 
by  circular  enterorrhaphy  or  by  the  Murphy  button. 

If  the  portion  to  be  removed  is  fixed  and  has  no  mesentery,  as 
the  cecum,  the  ascending  or  descending  portions  of  the  colon,  it  is 
often  wiser  to  make  the  operation  in  two  stages.  At  the  first  operation 
the  intestine  above  the  diseased  portion  is  united  by  lateral  anastomosis 
to  the  part  below  the  area  to  be  removed;  as,  for  instance,  uniting 
the  ileum  with  the  transverse  colon  in  disease  of  the  cecum,  or  the 
transverse  with  the  descending  or  sigmoid  colon  in  a  lesion  of  the  splenic 
flexure.  At  the  second  operation  the  diseased  area  is  removed,  and  the 
two  divided  ends  closed  by  a  purse-string  suture  and  reinforced  by 
additional  Lembert  sutures  or  an  omental  graft. 


Fig.  278. — Connell's  suture:    Method  of  inserting  needle  for  tying  the  last  knot.     (Kelly- 
Noble.) 

It  is  obvious  that  in  cases  of  acute  trauma  or  gangrene  both 
procedures  must  be  carried  out  at  the  same  time. 

Circular  Enterorrhaphy. — This  may  be  accomplished  by  means  of 
the  Cushing  or  Connell  suture.  If  the  former  method  is  employed, 
the  two  ends  of  the  divided  intestine  are  approximated  by  fixation 
sutures  or  small  forceps,  and  a  continuous  Cushing  suture  carried 
around  the  circumference.  Each  stitch  includes  the  serosa  muscularis 
and  submucosa,  and  is  introduced  about  one-quarter  of  an  inch  from 
the  free  border.  Great  care  should  be  taken  to  insure  complete 
closure  of  that  portion  of  the  bowel  between  the  two  layers  of  the  mesen- 
tery; and,  as  there  is  no  peritoneum  to  unite  at  this  point,  a  small 
portion  of  the  mesentery  may  be  inverted  to  insure  early  adhesion. 


OPERATIONS  ON   THE  INTESTINE 


555 


If  the  Coimell  suture  is  employed,  the  two  open  ends  of  the  gut 
to  be  united  are  placed  side  by  side,  with  the  mesenteric  border  of 
each  iu  contact.  Lateral  traction  sutures  are  next  placed  to  insure 
a  uniform  approximation.  A  continuous  suture  is  next  introduced, 
including  all  the  tunics  of  the  bowel,  and  by  changing  the  position 
of  the  traction  sutures  about  three-quarters  of  the  circumference  of 
the  gut  can  be  rapidly  united  from  within.  In  introducing  the  last 
few  stitches  the  edges  must  be  separated,  but  the  same  form  of  suture 
continued  until  the  entire  circumference  is  united.  The  two  extrem- 
ities of  the  suture  are  then  drawn  into  the  lumen  of  the  bowel  and 
again  outward  at  another  point  in  the  circumference  by  means  of  a 
blunt-pointed  Reverdin  or  ordinary  threaded  needle  introduced 
backward  (Fig.  278).  By  gentle  traction  on  the  suture  the  two 
mucous  surfaces  are  approximated  and  the  knot  tied.  As  soon  as 
the  remaining  ends  are  cut  away  the  knot  sinks  inward  and  leaves 
a  smooth  line  of  peritoneal  approximation  throughout  the  entire 
circumference. 


Fig.  279. — Murphy  button. 


Anastomosis  by  the  Murphy  Button. — This  is  the  quickest  and  often 
the  safest  method  of  intestinal  anastomosis.  The  Murphy  button 
(Fig.  279)  consists  of  two  perforated  metal  disks,  each  having  a  hollow 
metal  stem  of  such  a  size  that  one  telescopes  into  the  other,  and  is 
securely  held  in  place  by  a  spring  catch  acting  on  a  thread  on  the 
interior  of  the  female  stem.  By  this  contrivance  the  divided  ends 
of  the  intestine  can  be  securely  held  in  place  by  approximating  their 
inverted  peritoneal  coats.  Union  takes  place  externally,  and  the 
inverted  edges  eventually  slough,  allowing  the  closed  button  to  become 
free  and  to  pass  outward  along  the  intestine.  The  method  of  anasto- 
mosis by  the  button  is  as  follows:  A  continuous  suture  of  silk  or 
catgut  is  carried  around  the  free  edge  of  the  gut,  making  a  double 
turn  at  the  attachment,  of  the  mesentery.  One-half  of  the  button 
is  introduced  and  the  suture  tied  (Fig.  280);  the  other  half  is  placed 
in  the  other  end  of  the  divided  intestine  and  secured  in  the  same 
manner;  the  two  are  then  united  and  the  button  firmly  joined  by 
pressure  (Figs.  281  and  282).     After  careful  disinfection  and  suture 


550 


DISEASES  OF   THE  ABDOMEN 


of  the  divided  mesentery   the  united   intestine   is  dropped   into   the 
peritoneal  cavity  and  the  wound  closed  without  drainage. 


Fig.  280. — The  two  portions  of  the  Murphy  button  held  in  position  by  purse-string 
sutures.     (Richardson.) 


Fig.  281. — End-to-end  approximation;  button  in  position.     (Richardson.) 


Fig.  282. — End-to-end  union  of  intestine  with  a  Murphy  button.     (Richardson.) 

Maunsel's  Method  of  Enterorrhaphy. — In  this  operation  the  divided 
ends  of  the  intestine  are  united  by  two  silk  sutures,  one  at  the  mesen- 
teric border  and  one  at  the  free  opposite  border.     An  incision  is  then 


OPERATIONS  ON   THE  INTESTINE 


557 


made  longitudinally  into  the  bowel  an  inch  or  more  from  the  divided 
ends  on  the  distal  side  of  the  anastomosis,  and  through  this  incision 
the  two  silk  sutures  are  carried  (Fiji-.  283).  Drawing  these  sutures 
outward  through  the  longitudinal  wound  invaginates  the  two  approxi- 


fFTfOTvipiR 


Fig.  2S3. — Maunsel's  method:  first  two  sutures  brought  out  through  the  incision  in  the 

lower  segment. 

mated  portions,  which  are  eventually  drawn  outward  through  the 
distal  opening  (Fig.  284).  The  approximated  edges  are  then  united 
by  a  continuous  silk  suture  penetrating  all  three  coats.  When  this 
is  completed,  the  invaginated  gut  is  reduced  and  the  longitudinal 
wound  united  by  Lembert  sutures.  After  union  of  the  mesentery 
and  disinfection  of  the  parts  the  intestine  is  returned  to  the  abdominal 
cavity  and  the  parietal  wound  closed. 


Jl  {/    '    '  {V  )  '  i 
Fig.  2S4. — Maunsel's  method;  protruding  ends  ready  for  suture. 

Lateral  Anastomosis. — Lateral  anastomosis  is  often  necessary  to 
sidetrack  a  stricture  of  the  intestine  or  to  unite  the  bowel  after  enter- 
ectomy  when  one  portion  is  immovable  or  only  partly  surrounded  by 
peritoneum,  as  in  the  case  of  the  ascending  or  descending  colon. 


558  DISEASES  OF  THE  ABDOMEN 

It  generally  can  be  accomplished  by  the  use  of  the  Murphy  button 
introduced  as  in  gastroenterostomy. 

Abbe's  method  consists  in  closing  both  ends  of  the  divided  intestine 
by  purse-string  sutures,  placing  the  two  portions  of  the  bowel  side  by 
side  and  uniting  them  for  a  distance  of  two  or  three  inches  by  a  con- 
tinuous peritoneal  suture  of  silk  or  linen,  leaving  the  suture  long  at  each 
extremity  of  the  line.  Next  incise  both  portions  of  the  intestine  one- 
quarter  of  an  inch  from  the  suture  line,  introduce  a  second  line  of 
catgut  sutures  uniting  the  adjacent  cut  edges  of  the  gut,  and  carry  it 
entirely  around  the  opening;  then  introduce  an  outer  row  of  peritoneal 
sutures  on  the  side  opposite  to  the  first  row,  tying  each  extremity  to 
the  long  ends  left  of  the  first  peritoneal  suture. 

Colostomy. — This  operation  is  indicated  in  carcinoma  of  the  sigmoid 
or  rectum,  and  in  other  cases  in  which  temporary  or  permanent 
absence  of  fecal  discharges  through  the  rectum  is  desirable.  Maydl's 
method  consists  in  making  an  incision  in  the  left  inguinal  region 
parallel  with  the  fibres  of  the  external  oblique  aponeurosis,  and  carry  - 


Fig.  285. — Inguinal  colostomy.     (Tillmanns.) 

ing  the  incision  through  all  layers  until  the  peritoneal  cavity  is  opened. 
The  upper  part  of  the  sigmoid  flexure  is  found  and  drawn  outward 
through  the  wound.  A  glass  rod  is  passed  through  its  mesentery  and 
allowed  to  project  on  either  side  on  the  abdominal  wall,  to  prevent 
return  of  the  loop  or  gut.  The  peritoneum  may  be  stitched  to  the 
protruding  intestine  and  the  wound  partly  closed  (Fig.  285).  When 
possible,  the  opening  into  the  bowel  should  be  delayed  for  twenty -four 
or  forty-eight  hours,  until  the  peritoneal  cavity  is  thoroughly  sealed 
by  adhesions.  Colostomy  occasionally  may  be  necessary  at  a  higher 
point  in  the  colon.  In  the  transverse  portion  there  is  little  difficulty 
in  withdrawing  a  knuckle  of  the  bowel;  but  in  the  cecum,  ascending  or 
descending  colon,  this  may  be  impossible  if  there  is  no  mesentery. 
In  these  cases  the  presenting  portion  of  the  colon  may  be  united  to  the 
parietal  peritoneum,  and  the  edges  of  the  opening  kept  apart  by  gauze 
packing  until  adhesions  have  formed,  after  which  the  bowel  may  be 
incised.  Weir's  method  of  establishing  a  permanent  artificial  anus 
is  to  divide  completely  the  sigmoid,  close  the  distal  portion  and  drop 


APPENDICITIS  559 

it  back  into  the  pelvic  cavity,  then  carry  the  proximal  portion  beneath 
the  skin  to  an  opening  just  over  the  crest  of  the  ilium,  to  which  its 
edges  are  united.  This  insures  freedom  from  fecal  invasion  of  the 
lower  segment  and  an  artificial  anus  which  can  in  a  measure  be 
controlled. 

APPENDICITIS. 

The  vermiform  appendix  is  an  anatomic  relic  due  to  gradual  reduc- 
tion in  size  of  the  cecum.  In  man  and  the  anthropoid  apes  it  is 
found  as  a  diminutive  blind  intestinal  tube  opening  into  the  caput 
coli.  It  possesses  the  same  anatomic  structure  as  the  intestine.  Its 
mucous  membrane  is  richly  supplied  with  lymphoid  tissue.  So 
abundant  is  this  tissue  that  sometimes  the  appendix  is  spoken  of  as 
the  abdominal  tonsih  Its  cecal  orifice  is  guarded  by  a  fold  of  mucous 
membrane,  the  valve  of  Gerlach.  Under  ordinary  conditions  the 
abundant  secretion  of  the  mucous  membrane  of  the  appendix  finds  its 
way  easily  into  the  intestine,  and  the  valve  of  Gerlach  serves  to 
prevent  the  entrance  of  any  considerable  amount  of  intestinal  matter. 
If  the  mucous  membrane  of  the  cecum  becomes  swollen  as  a  result 
of  some  digestive  disturbance  or  inflammatory  process,  the  orifice  may 
become  temporarily  occluded,  causing  retention  of  the  secretions  of 
the  appendix.  The  muscular  efforts  of  the  appendix  to  rid  itself  of 
this  excess  of  mucus  may  cause  pain,  and  constitutes  the  condition 
known  as  appendicular  colic.  Other  conditions  may  give  rise  to  this 
same  condition,  as  the  presence  within  the  lumen  of  the  appendix 
of  a  small  amount  of  fecal  matter,  the  fluid  portion  of  which  has 
been  absorbed,  leaving  a  small  oval  mass  which  resembles  in  appearance 
a  grape-  or  date-seed  (a  circumstance  which  accounts  for  the  popular 
impression  that  the  presence  of  such  seeds  is  the  cause  of  appendicitis1). 
Expulsive  muscular  efforts  on  the  part  of  the  appendix  to  rid  itself 
of  this  foreign  body  give  rise  also  to  appendicular  colic.  If  for  any 
reason  this  occlusion  of  the  lumen  of  the  appendix  is  not  relieved, 
the  organ  becomes  distended  with  mucus;  pressure  on  the  mucous 
membrane  causes  anemia  and  diminished  resistance;  the  pathologic- 
micro-organisms  always  present  (Bacillus  coli  and  others)  attack  the 
anemic  membrane  and  give  rise  to  an  inflammatory  process  which 
constitutes  the  acute  catarrhal  form  of  appendicitis.  If  the  obstruction 
is  speedily  relieved,  this  may  disappear  without  damage  to  the  mem- 
brane. Generally,  however,  there  has  been  some  necrosis  and  loss 
of  tissue,  which  by  later  cicatrization  and  contraction  gives  rise  to 
stricture  of  the  appendix,  a  condition  which  favors  subsequent  recur- 
rence of  the  trouble,  and  constitutes  one  of  the  forms  of  relapsing 
or  recurrent  appendicitis.  If  in  an  acute  catarrhal  appendicitis  the 
distension  is  not  promptly  relieved,  extensive  infiltration  of  the  mucous 

1  Some  years  ago  McBurney  stated  that  he  had  seen  only  one  grape-seed  in  the  appendix, 
and  that  was  discovered  by  accident  during  a  laparotomy  for  another  condition.  The 
appendix  in  this  instance  was  healthy. 


560  DISEASES  OF   THE  ABDOMEN 

membrane  and  of  the  submucous  and  muscular  coats  may  occur  from 
extension  of  the  inflammatory  process,  constituting  an  acute  interstitial 
appendicitis,  in  which  the  organ  appears  erect,  hot,  swollen,  and 
intensely  red.  If  the  process  extends,  and  especially  if  there  is  added 
thrombosis  of  the  appendicular  vessels  or  the  pressure  of  a  concretion 
cutting  off  or  seriously  compromising  the  blood  supply,  necrosis  occurs, 
which  may  be  limited  in  extent,  giving  rise  to  a  perforation,  acute 
perforative  appendicitis,  or  a  large  part  or  the  whole  of  the  organ  may 
slough,  gangrenous  appendicitis. 

In  the  simple  catarrhal  variety  there  is,  as  a  rule,  no  involvement  of 
the  neighboring  peritoneum;  if,  however,  the  process  extends  to  the 
other  coats  of  the  appendix,  and  especially  if  the  infecting  agent  is  a 
virulent  one,  peritonitis  may  develop,  even  without  perforation,  from 
a  transudation  of  septic  material  through  the  infiltrated  walls  of  the 
organ.  When  perforation  occurs,  peritonitis  always  results  unless  the 
appendix  is  located  behind  the  peritoneal  membrane,  as  it  occasionally 
is  in  the  retrocolic  variety.  As  in  other  peritoneal  infections,  the 
resulting  peritonitis  may  be  localized  or  diffuse.  If  localized,  it  may 
be  plastic  and  result  in  a  matting  together  of  the  neighboring  viscera. 
This  form  is  fairly  common,  and  occurs  often  in  cases  before  perforation 
has  occurred.  In  the  majority  of  cases,  however,  in  which  perforation 
occurs,  an  intraperitoneal  abscess  forms,  the  walls  of  which  are  formed 
by  a  mass  of  the  intestine  and  omentum  matted  together  with  plastic 
exudate,  separating  the  septic  focus  completely  from  the  general 
peritoneal  cavity.  This  constitutes  an  appendicular  abscess.  If  the 
inflammatory  process  in  the  peritoneum  which  results  from  a  rupture 
of  an  inflamed  appendix  is  not  quickly  walled  off  by  adhesions,  or  if 
the  amount  of  septic  fluid  which  escapes  is  large  and  covers  an  extensive 
area,  or  if  the  virulence  of  the  infecting  micro-organisms  is  great,  a 
diffuse  spreading  or  general  peritonitis  results.  In  abnormally  placed 
appendices,  outside  the  general  peritoneal  sac,  abscesses  may  be 
produced  which  never  communicate  with  that  cavity.  Thus  in 
retrocecal  or  retrocolic  appendices  the  abscess  lies  behind  the  peri- 
toneum in  the  flank,  often  as  high  as  the  kidney.  Appendicular 
abscesses  have  also  been  reported  on  the  left  side  of  the  abdomen  or 
pelvis,  and  in  the  sac  of  a  femoral  hernia. 

Appendicular  abscesses  may  develop  slowly  or  rapidly,  depending 
largely  on  the  virulence  of  the  infection  and  the  resistance  of  the 
individual.  They  may  rupture  into  one  of  the  hollow  viscera,  exter- 
nally, or  into  the  free  peritoneal  cavity,  and  thus  occasion  an  acute 
spreading  peritonitis. 

Symptoms. — The  symptoms  of  acute  appendicitis  in  the  order  of 
onset,  are:  pain,  often  at  first  in  the  epigastrium,  shifting  in  a  few  hours 
to  the  right  iliac  region;  nausea  or  vomiting,  most  commonly  occurring 
from  two  to  four  hours  after  the  onset  of  the  pain;  abdominal  tender- 
ness, maximal  in  the  right  lower  quadrant  of  the  abdomen  at  McBur- 
ney's  point;  elevation  of  temperature,  generally  beginning  within  a 


APPENDICITIS  561 

few  hours  after  the  onset  of  the  pain;  leukocytosis,  which  is  very  apt 
to  accompany  the  rise  in  temperature. 

The  order  of  onset  of  symptoms  in  acute  appendicitis  is  of  the 
greatest  importance.  J.  B.  Murphy  lays  much  stress  on  this  point 
and  states  that  if  nausea,  vomiting,  or  fever  precedes  the  pain,  the 
case  is  not  one  of  appendicitis.  Pain  is  constant  and  uniform  and 
practically  never  absent  as  an  initial  symptom;  is  apt  to  reach  its 
height  in  from  four  to  six  hours,  but  may  persist  with  great  violence 
for  a  considerably  longer  time.  Sudden  cessation  of  the  severe  pain 
of  appendicitis  in  the  first  thirty-six  hours  usually  means  either  dis- 
charge of  contents  into  the  cecum,  perforation,  or  complete  gangrene. 
It  is  often  an  ominous  sign,  and  must  not  be  mistaken  for  an  improve- 
ment in  the  condition.  When  followed  in  a  short  time  by  an  increase 
of  steady  pain  over  a  larger  area,  with  increase  in  the  area  of  tenderness 
and  rigidity,  it  means  developing  peritonitis.  Primary  nausea  and 
vomiting  is  reflex,  usually  occurs  a  few  times  only  and  ceases;  if  it 
continues  or  becomes  persistent,  it  is  indicative  of  peritonitis.  Ab- 
dominal tenderness  is  often  at  first  diffuse  and  indefinite,  but  soon 
localizes  over  the  appendix.  ^Yhen  associated  with  rigidity,  it  means 
irritation  of  the  parietal  peritoneum  and  is  a  most  valuable  diagnostic 
sign.  Tenderness  may  be  slight  and  rigidity  absent  in  appendicitis 
situated  deep  in  the  pelvis,  or  behind  the  colon,  even  when  the  process 
is  acute.  Development  of  a  tumor  or  mass  is  due  to  inflammatory 
exudate  surrounding  the  inflamed  appendix,  to  thickened  omentum, 
or  to  an  abscess  surrounded  by  exudate.  The  site  of  maximal  tender- 
ness is  often  of  aid  in  determining  the  position  of  the  appendix.  In- 
crease in  the  leukocyte  count  and  percentage  of  polymorphonuclears 
varies  with  the  amount  of  inflammation  present.  A  low  count  with 
high  polynuclear  percentage  may  be  present  in  acute  gangrene  and 
suggests  a  low  degree  of  resistance.  Some  degree  of  elevation  of 
temperature  is  seldom  absent  in  the  acute  infective  cases  in  the  early 
stage.  Cases  of  acute  gangrene  occasionally  are  seen,  however, 
with  so  slight  an  elevation  of  temperature  that  the  reaction  seems 
out  of  proportion  to  the  severity  of  the  lesion.  There  is  no  typical 
temperature  curve,  and  slight  reaction  counts  little  in  estimating  the 
severity  of  the  case,  although  it  often  reaches  102°  or  103°  in  the 
first  twenty-four  hours.  The  pulse  rate  usually  conforms  to  the  tem- 
perature, except  in  the  more  acute  forms  of  gangrene  and  peritoneal 
sepsis,  when  it  may  be  disproportionately  rapid  and  weak. 

The  symptoms  as  described  apply  to  the  typical  case  of  acute 
appendicitis,  and  vary  with  the  severity  of  the  type.  In  appendicular 
colic,  pain  and  perhaps  slight  tenderness  are  the  only  symptoms. 
In  catarrhal  appendicitis,  vomiting  and  slight  elevation  of  tem- 
perature are  present  in  addition;  rigidity  is  generally  absent.  As 
the  more  severe  types  are  reached,  the  exudative,  perforative  or 
gangrenous,  both  local  and  constitutional  symptoms  are  of  the  type 
described,  varying  with  the  severity  of  the  case. 
36 


562  DISEASES  OF   THE   ABDOMEN 

Course. — In  appendicular  colic,  the  pain  and  tenderness  usually 
subside  within  twenty-four  or  thirty-six  hours.  In  catarrhal  appendi- 
citis, improvement  in  the  symptoms  usually  begins  about  the  end  of 
forty-eight  hours  and  all  tenderness  will  have  disappeared  within 
three  or  four  days. 

The  line  of  demarcation  between  catarrhal  appendicitis  and  the 
milder  exudative  types  cannot  he  definitely  drawn,  one  condition 
merging  into  the  other;  in  the  latter  the  symptoms  being  a  little  more 
severe  and  protracted,  the  tenderness  of  longer  duration,  and  often 
accompanied  by  muscular  rigidity. 

When  there  is  an  accumulation  of  pus  or  mucopurulent  fluid  in  an 
occluded  appendix  without  perforation,  empyema  of  tin-  appendix, 
the  symptoms  are  still  more  severe,  the  leukocyte  count  especially 
being  higher.  Local  perforation  may  cause  a  sudden  cessation  of 
pain,  soon  to  be  followed  by  an  increase  of  pain,  tenderness  and 
rigidity  and  all  the  symptoms  of  a  peritonitis  which  may  remain 
localized  or  become  diffuse.  If  localized,  the  case  becomes  one  of  an 
appendix  abscess  type  already  described.  Chills  and  sweating  may 
occur  in  the  septic  types  of  appendicitis,  especially  at  the  onset  of 
gangrene.  The  symptoms  of  peritonitis  due  to  appendicitis  have 
already  been  described  under  the  heading  of  "acute  appendicitis." 

Absence  of  pain  in  appendicitis  is  very  exceptional.  Occasionally 
cases  are  encountered  in  which  the  disease  goes  on  to  the  formation 
of  an  abscess  or  a  spreading  peritonitis  without  acute  pain.  Absence 
of  marked  fever  is  more  frequent.  The  writer  has  on  several  occasions 
found  a  gangrenous  appendix  and  a  diffuse  spreading  peritonitis  in 
patients  in  whom  the  pulse  and  temperature  were  both  below  100. 

Diagnosis. — The  diagnosis  of  appendicitis  in  its  early  stages  is  usually 
easy.  In  the  presence  of  symptoms  of  beginning  inflammation  in  the 
right  iliac  fossa  in  women,  one  must  exclude  salpingitis,  in  which  the 
point  of  maximum  tenderness  is  below  McBurney's  point,  and  is  gen- 
erally more  easily  reached  by  vaginal  examination.  In  this  affection 
there  is  usually  a  history  of  previous  infection  either  of  a  puerperal 
nature,  the  result  of  abortion  or  an  invasion  by  the  gonococcus.  The 
uterus  is  more  or  less  fixed  and  the  roof  of  the  pelvis  is  rigid.  Typhoid 
perforation  can  be  excluded  by  the  history.  An  ulcerating  carcinoma 
of  the  intestine,  by  the  absence  of  symptoms  of  obstruction,  and  the 
loss  of  weight  and  strength  which  usually  accompanies  this  disease 
before  ulceration  and  perforation  take  place.  Renal  colic  may  stimu- 
late very  closely  appendicular  colic,  and  a  diagnosis  between  the  two 
is  not  always  possible.  Tenderness  over  the  kidney,  pain  radiating 
to  the  groin  and  testicle,  absence  of  fever  and  muscular  rigidity,  and 
presence  of  blood  in  the  urine,  would  point  to  a  renal  origin  of  the 
pain.  Pain  in  the  right  inguinal  region  and  tenderness  over  Mc- 
Burney's point  are  frequently  present  in  women  just  before  or  during 
menstruation,  but  without  fever  or  muscular  rigidity.  In  hysteric 
subjects  the  pain  may  be  severe,  and  require  codiene  or  morphine  for 


APPENDICITIS  563 

its  relief.  Appendicular  abscess  may  be  simulated  by  a  strangulated 
ovarian  cyst,  by  a  rapidly  growing  intestinal  sarcoma,  by  a  retro- 
peritoneal abscess  of  renal  origin  or  from  lymphatic  infection  From 
the  lower  extremity,  genitals  or  pelvic  organs,  by  tuberculosis  or 
actinomycosis  of  the  appendix  or  cecum,  and  by  an  acute  inflammation 
of  a  congenital  or  acquired  intestinal  diverticulum.  These  can  only 
be  excluded  by  a  carefully  taken  history,  and  in  the  case  of  tuber- 
culosis by  the  blood  count.  Psoas  or  iliac  abscess  may  rarely  simulate 
this  condition.  These  generally  can  be  excluded  by  the  history  of 
disease  of  the  spine  or  pelvic  bones,  and  by  the  chronicity  of  the 
affection. 

In  palpating  the  contents  of  the  iliac  fossa  Meltzer  has  recently 
called  attention  to  the  advantages  to  be  gained  by  a  contraction 
of  the  iliopsoas  musde.  By  instructing  the  patient  to  raise  the  entire 
limb  from  the  bed  the  muscle  is  brought  nearer  to  the  anterior  ab- 
dominal wall,  and  any  structure  lying  upon  it  can  be  more  easily 
palpated. 

In  the  presence  of  symptoms  of  general  peritonitis  without  localized 
signs,  one  must  consider,  in  addition  to  the  appendicular  and  tubal 
origins  of  such  inflammations,  a  perforated  gall-bladder,  perforation 
of  an  ulcer  of  the  stomach  or  duodenum,  acute  pancreatitis,  divertic- 
ulitis, and  intestinal  obstruction.  In  the  first  four  conditions  the 
pain,  tenderness,  and  rigidity  begin  in  the  upper  part  of  the  abdomen, 
whereas  in  appendicitis  they  begin  below.  In  gall-bladder  disease  and 
in  perforations  of  the  stomach  or  duodenum  there  is  usually  a  history 
of  previous  disease  or  disturbed  function  in  these  organs.  In  intestinal 
obstruction  obstipation  exists  before  symptoms  of  peritonitis,  which 
generally  results  from  a  perforation  of  the  bowel  above  the  seat  of  ob- 
struction. In  many  of  these  late  cases  an  accurate  diagnosis  is  im- 
possible except  by  exploratory  operation. 

Treatment. — Without  entering  into  a  discussion  of  the  various 
methods  which  have  been  employed  in  the  treatment  of  this  con- 
dition in  the  past,  it  may  be  stated  that  at  the  present  time  the  con- 
sensus of  opinion  among  surgeons  is  that  appendicular  colic  without 
fever,  muscular  rigidity,  or  leukocytosis  can  be  safely  treated  by  rest, 
an  ice-bag,  fasting,  and  an  opiate  if  necessary,  until  the  attack  has 
subsided;  to  be  followed  in  the  interval  by  removal  of  the  organ. 
(  'atarrhal  appendicitis  which  has  passed  the  acuteness  of  the  attack 
with  a  declining  temperature,  pulse  rate,  and  leukocytosis,  and  with 
diminishing  pain  and  tenderness,  may  also  be  treated  in  the  same 
manner.  All  other  cases  should  be  operated  upon  as  soon  as  the 
diagnosis  is  made,  if  the  condition  of  the  patient  warrants  the  ad- 
ministration of  an  anesthetic  and  the  surroundings  are  such  as  to 
admit  of  an  aseptic  operation  with  competent  assistants.  In  interval 
cases  the  mortality  following  the  operation  should  be  less  than  1 
per  cent.;  in  early  acute  cases  when  the  inflammation  is  limited  to  the 
appendix  the  mortality  should  not  exceed  2  or  3  per  cent.;  in  abscess 


564  DISEASES  OF   THE  ABDOMEN 

cases,  not  greater  than  5  per  cent.;  In  cases  with  diffuse  peritonitis 
the  modern  operative  technic  has  caused  great  reduction  in  the  mor- 
tality, but  in  late,  neglected  cases,  with  wide-spread  peritonitis  the 
prognosis  is  still  very  grave. 

In  cases  in  which  the  conditions  are  such  as  to  preclude  the  possi- 
bility of  an  operation,  the  treatment  should  be  rest,  ice,  opium,  and 
starvation,  preceded,  if  possible,  by  evacuation  of  the  stomach  and 
bowels.  These  measures  will  serve  to  diminish  peristalsis  and  favor 
subsidence  of  inflammation,  or  at  least  do  away  with  the  factors 
which  tend  to  favor  its  rapid  spread.  Under  no  circumstances  should 
cathartics  be  given  to  patients  in  whom  there  is  a  possibility  of  an 
acute  appendicitis.  The  author  believes  cathartic  medication  to  be 
responsible  for  early  perforation  in  a  large  number  of  cases. 

Intermuscular  Appendectomy  (McBurney's  Operation). — This  is 
the  simplest  and  safest  operation  on  the  appendix.  It  is  indicated 
in  all  cases  during  the  interval  between  the  attacks,  when  there  is 
no  reason  to  expect  serious  adhesions  or  other  complications  which 
render  a  large  opening  necessary.  It  is  also  indicated  in  acute  cases 
when  the  inflammation  is  limited  to  the  appendix,  and  when  the 
abdominal  cavity  can  be  tightly  closed  after  removal  of  the  disease. 
An  incision  two  or  three  inches  in  length  is  made  parallel  with  the 
fibres  of  the  external  oblique  aponeurosis,  the  centre  of  which  will 
lie  a  little  to  the  outer  side  of  McBurney's  point.  This  divides  the 
skin  and  subcutaneous  tissues  down  to  the  aponeurosis.  The  apon- 
eurosis is  then  split  in  the  direction  of  its  fibres  and  well  retracted, 
exposing  the  internal  oblique,  the  fibres  of  which  are  next  separated 
by  blunt  dissection  and  retracted  in  the  opposite  direction.  The 
transversalis  fibres  can  then  be  separated  in  the  same  manner,  which 
exposes  the  thin  transversalis  fascia  and  subperitoneal  fat.  These 
structures  are  carefully  divided  'and  the  peritoneum  drawn  upward 
in  a  transverse  fold  by  two  mouse-toothed  forceps,  and  opened  by  the 
scissors  or  scalpel.  The  colon  will  generally  be  found  immediately 
beneath  this  opening,  and  if  one  of  its  longitudinal  bands  is  followed 
downward  while  the  bowel  is  being  drawn  upward  into  the  wound,  it 
will  be  found  to  lead  directly  to  the  base  of  the  appendix.  In  certain 
rare  instances  the  colon  will  not  be  found  in  the  iliac  region.  In 
these  cases  it  will  either  be  found  in  the  right  lumbar  or  hypochondriac 
region,  due  to  an  early  attachment  of  the  appendix  and  a  failure  of 
descent;  or  in  the  central  zone  of  the  abdomen,  due  to  an  incomplete 
rotation  of  the  gut  at  an  earlier  period  of  development.  If  no  adhesions 
exist,  the  appendix  and  cecum  can  be  drawn  outward  through  the 
wound,  and  the  peritoneum  protected  by  one  or  two  small  pads  of 
gauze.  The  mesentery  of  the  appendix  is  next  ligated  by  passing  a 
stout  catgut  ligature  through  its  fold  near  the  junction  of  the  appendix 
with  the  cecum,  and  tying  it  well  below  the  attachment  of  the  mesen- 
tery to  the  appendix.  If  the  mesentery  is  large,  it  should  be  ligated 
in  sections.     The  appendix  is  next  cut  from  its  mesentery  and  held 


APPENDICITIS  565 

upward  by  an  assistant  while  the  surgeon  surrounds  its  base  by  a  silk 
or  fine  chromicized  catgut  purse-string  suture.  When  this  is  in  place, 
the  ends  should  be  knotted,  but  not  tied,  and  held  by  an  assistant. 
The  surgeon  next  applies  two  clamps  just  above  the  cecum, 
divides  the  appendix  between  the  clamps,  and  cauterizes  the  stump, 
which  is  then  inverted  into  the  cecum  by  a  pair  of  fine  forceps 
grasping  the  cut  margins  and  pushing  them  inward.  During  this 
maneuvre  the  assistant  tightens  the  purse-string  suture  and  the 
small  forceps  is  withdrawn.  By  this  method,  which  is  known  as 
the  Dawbarn  method,  the  stump  is  completely  inverted  and  buried, 
leaving  only  a  small  puckered  depression  at  the  surface  of  the 
cecum.  The  method  is  the  ideal  one,  and  should  be  employed 
whenever  possible.  If,  however,  there  is  much  infiltration  of  the 
cecum  or  appendix  -which  prevents  its  inversion  without  too  much 
bruising,  or  if  there  exist  dense  adhesions  which  prevent  the  drawing 
upward  of  the  cecum  into  the  wound,  the  appendix  should  simply 
be  ligated  near  its  base  wTith  chromicized  catgut,  divided  with 
scissors,  and  the  exposed  mucous  membrane  treated  by  a  drop  of 
pure  carbolic  acid  or  the  actual  cautery.  Before  returning  the  bowel 
to  the  abdomen  it  should  be  touched  with  hydrogen  peroxide  and 
douched  with  salt  solution.  If  there  is  reason  to  suppose  that  the 
peritoneal  cavity  has  been  contaminated,  the  wound  should  be  well 
retracted  and  the  surrounding  intestines  carefully  wiped  by  moist 
gauze  sponges  or  douched  with  sterile  salt  solution. 

The  peritoneum  is  closed  with  a  continuous  catgut  suture,  the 
muscles  allowed  to  fall  together  and  held  by  one  or  two  catgut  inter- 
rupted stitches,  the  aponeurosis  united  in  the  same  manner  as  the 
peritoneum,  and  the  skin  wound  closed  by  two  or  three  silkworm- 
gut  or  silk  sutures.  A  small  subcutaneous  rubber  tissue  drain  may 
be  left  for  twenty-four  or  forty-eight  hours  if  there  has  been  con- 
tamination. If  primary  healing  occurs,  the  patient  may  leave  the 
bed  on  the  eighth  or  ninth  day. 

All  authorities  are  practically  unanimous  in  accepting  the  rule 
as  regards  early  operation  in  acute  cases  seen  within  the  first  thirty- 
six  or  forty-eight  hours.  In  a  later  stage  of  the  inflammatory  process, 
when  perforative  periappendicular  abscess  or  peritonitis  are  present 
with  signs  of  constitutional  sepsis  of  greater  or  less  degree,  the  condition 
apt  to  be  found  from  the  second  to  the  fifth  day,  there  is  some  differ- 
ence of  opinion  regarding  the  proper  treatment.  It  is  in  this  type 
that  Ochsner  insists  strongly  on  his  non-operative  treatment,  con- 
sisting in  prohibition  of  fluids  or  food  by  mouth,  or  of  catharsis,  the 
employment  of  gastric  lavage,  saline  solution  by  rectum,  and  rectal 
feeding.  The  majority  of  surgeons,  however,  believe  that  even  in  this 
class  of  cases,  prompt  removal  of  the  appendix,  with  proper  drainage,  is 
the  preferable  procedure,  provided  the  operation  can  be  performed  under 
proper  surroundings  by  a  skilled  surgeon,  and  if  modern  principles 
of  technic  are  employed,  i.  e.,  a  minimum  of  trauma  and  exposure 


566  DISEASES  OF   THE  ABDOMEN 

of   intra-abdominal  contents,  a  quick   operation,  and   adequate,   but 
not  excessive  drainage. 

The  choice  of  incision  in  this  type  of  case  is  a  matter  of  some  differ- 
ence of  opinion,  the  rectus,  or  Kammerer  incision  being  preferred  by 
some  surgeons  on  account  of  better  area  of  exposure;  the  intermuscular, 
or  McBurney,  by  others  because  of  the  better  drainage  and  lessened 
danger  of  spreading  infection  toward  the  central  portions  of  the  abdo- 
men. If  the  process  is  an  abscess  or  localized  peritonitis,  great  care  must 
be  taken  to  avoid  spreading  the  infection  in  the  peritoneal  cavity. 
Gauze  pads  should  be  used  sparingly,  if  at  all,  and  never  pushed  through 
an  infected  area  into  clean  peritoneum.  Pus  should  be  evacuated,  a 
quick  search  made  for  the  appendix,  which  is  removed,  if  possible, 
without  too  much  interference  with  protective  adhesions.  It  is  much 
better  to  leave  the  removal  of  the  appendix  to  a  second  operation  than 
to  prolong  the  search  too  far  or  endanger  the  patient  by  severe 
trauma.  When  there  are  no  limiting  adhesions,  and  a  more  or  less 
extensive  diffuse  peritonitis,  quick  removal  of  the  appendix,  with 
removal  of  the  exudate  with  the  least  possible  trauma,  preferably 
by  suction  apparatus  or  by  flushing  with  saline  solution  through  a 
Chamberlin  or  Blake  tube,  with  the  insertion  of  cigarette  drains  to 
the  region  of  the  stump  and  often  to  the  pelvis,  should  be  the  procedure. 
It  is  important  to  bear  in  mind,  however,  that  the  peritoneum  is  capa- 
ble of  taking  care  of  a  considerable  amount  of  exudate  if  the  source 
of  infection  is  removed  and  the  peritoneal  surfaces  are  not  traumatized; 
also,  that  much  of  the  cloudy  serous  exudate  present  in  these  cases  is 
either  sterile  or  very  mildly  infected.  It  is  in  this  class  of  cases  that  the 
mortality  has  been  so  greatly  reduced  by  a  recognition  of  these  principles. 

Chronic  Appendicitis. — The  course  of  chronic  appendicitis  shows 
many  varieties: 

First,  the  recurrent  type,  with  attacks  of  typical  acute  appendicitis 
of  varying  degrees  of  severity,  chiefly,  however,  of  the  mild  or  moder- 
ately severe  type,  followed  by  intervals  of  complete  freedom  from 
pain,  tenderness,  or  other  symptoms,  the  free  interval  being  of 
varying  length. 

Second,  a  type  similar  to  the  first,  except  that  in  the  interval  be- 
tween the  attacks,  tenderness  does  not  entirely  disappear.  In  this 
type,  the  intervals  of  freedom  from  exacerbations  are  not  apt  to  be 
so  long,  as  persistent  tenderness  generally  means  retention  of  foreign 
material  in  the  appendix. 

The  third  type  is  that  in  which  there  are  no  true  exacerbations  of  the 
symptoms,  but  more  or  less  persistent  pain  and  tenderness,  varying 
in  severity  from  time  to  time,  but  never  absent  for  any  considerable 
period. 

The  fourth  type  is  spoken  of  as  "appendicular  dyspepsia"  in  which 
the  symptoms  are  referred  not  to  the  appendix  itself,  but  generally 
to  the  stomach,  often  with  no  pain  or  tenderness  in  the  region  of 
the  appendix. 


APPENDICITIS  56' 

All  types  of  chronic  appendicitis  are  apt  to  be  associated  with 
constipation  and  more  or  less  gastric  indigestion. 

Postoperative  Treatment.  In  interval  cases  and  in  early  acute 
conditions  when  the  abdomen  is  tightly  closed,  little  postoperative 
interference  is  accessary  if  the  ease  progresses  favorably.  Morphine 
in  small  doses  may  be  required  during  the  first  twenty-four  hours 
to  relieve  pain.  The  bowels  should  be  moved  on  the  third  or  fourth 
day.  For  this  small  doses  of  calomel  may  be  administered,  followed 
by  a  saline  draught,  and  enemata  if  necessary 

If  much  morphine  has  been  used,  there  may  be  considerable  diffi- 
culty in  bringing  about  a  movement,  on  account  of  the  tendency 
to  nausea  which  prevents  the  free  use  of  salts.  In  these  cases  the 
frequent  use  of  high  enemata  will  generally  be  successful  if  there  is  no 
peritonitis.1  If  the  pulse  and  temperature  are  normal,  the  dressing 
need  not  be  changed  for  six  or  eight  days.  Obstinate  vomiting  after 
operation  generally  can  be  relieved  by  lavage,  followed  by  absolute 
rest  of  the  stomach,  not  even  water  being  allowed.  The  practice  of 
giving  medicines  to  relieve  postoperative  vomiting  is  to  be  condemned, 
as  they  always  serve  to  aggravate  the  condition. 

Continued  pain  and  vomiting  after  operation  point  to  peritoneal 
irritation;  and  if  the  pulse  and  temperature  are  elevated  and  the 
abdominal  tenderness,  rigidity  and  distension  are  increased,  there 
is  strong  reason  to  suspect  a  spreading  peritonitis.  In  these  cases 
the  wound  may  be  reopened  under  anesthesia  and  the  peritonitis 
treated  as  indicated  above.  Secondary  operations  for  postoperative 
spreading  peritonitis  are  rarely  successful,  however,  and  often  it  is 
wiser  to  carry  out  vigorous  palliative  treatment,  repeated  enemata, 
gastric  lavage  for  vomiting,  saline  by  rectum,  hypodermoclysis,  or 
infusion,  rather  than  to  reopen  the  abdomen.  In  acute  cases  in  which 
drainage  is  employed,  the  wound  should  be  inspected  frequently  and 
the  outside  dressings  changed  as  often  as  they  become  saturated 
with  the  wound  secretions.  If  the  temperature  and  pulse  remain 
elevated,  and  if  tenderness  and  rigidity  are  present,  the  drains  should 
be  removed  and  any  retained  pus  evacuated.  Digital  exploration  of 
the  wound  with  the  gloved  hand  will  often  enable  the  surgeon  to 
recognize  a  collection  of  pus  by  the  induration,  which  may  not  be 
apparent  on  superficial  abdominal  palpation.  Such  deep-seated 
collections  of  pus  are  often  drained  best  by  rubber  tubes  until  the 
acuteness   of  the  symptoms  has  subsided.    As  soon  as  the  sinuses 

1  In  a  recent  communication,  entitled  Catharsis  in  Abdominal  Surgery,  Dr.  L.  R.  G. 
Crandon,  of  Boston,  condemns  the  use  of  cathartic  medicines  by  the  mouth  in  cases 
of  acute  abdominal  inflammation  involving  the  alimentary  canal.  He  advises  high  ene- 
mata both  before  and  after  operation.  His  best  results  were  obtained  by  the  use  of  the 
following  formula: 

R- — Saturated  solution  of  Epsom  salt, 
Turpentine, 

Glycerin,  aa      §ij 

Water,  5vj — M. 


568  DISEASES  OF   THE  ABDOMEN 

are  reasonably  clean  and  granulations  appear,  further  packing  is 
unnecessary  and  only  delays  recovery. 

In  the  treatment  of  a  generalized  peritonitis  the  chief  indications 
are  to  limit  the  amount  of  absorption  from  the  peritoneal  cavity 
and  to  promote  rapid  elimination.  The  former  is  best  accomplished 
by  placing  the  patient  in  the  Fowler  position  (Fig.  28)  to  allow  the 
septic  material  to  gravitate  toward  the  pelvis,  where  absorption  is 
slow;  the  latter,  by  introducing  into  the  system  large  quantities  of 
fluid.  At  first  reliance  must  be  placed  upon  rectal  salines,  which 
should  be  given  slowly  at  a  temperature  of  100°  F.,  a  short  rectal 
nozzle  being  employed.  Calomel  should  be  administered  as  soon  as 
the  postanesthetic  vomiting  has  ceased,  followed  by  salines  and  high 
enemata.  If  the  medicines  are  rejected  by  the  stomach,  it  should  be 
washed  out  and  salts  introduced  through  the  stomach-tube.  Enemata 
of  turpentine,  glycerin, 'and  a  saturated  solution  of  Epsom  salt  should 
be  given.  When  the  rectum  becomes  intolerant,  intravenous  infusions 
are  of  the  greatest  value  in  stimulating  the  secretion  of  urine  and  inducing 
active  diaphoresis.  Cardiac  stimulants,  as  strychnine,  digitalis,  caffeine, 
and  alcohol,  should  be  freely  given.  Sponge-baths  and  hot  packs 
will  often  relieve  the  intense  restlessness  and  high  temperature. 
The  practice  of  abandoning  patients  to  their  fate  who  develop  general- 
ized peritonitis  cannot  be  too  strongly  condemned.  While  the  great 
majority  of  such  patients  eventually  succumb  in  spite  of  all  treatment, 
desperate  cases  occasionally  are  saved  by  energetic  and  persistent 
treatment.  The  author  has  recently  seen  such  a  patient  recover 
after  days  of  continuous  vomiting  of  intestinal  matter,  enormous 
distension  of  the  abdomen,  a  temperature  of  108.5°  F.,  and  a  pulse 
that  could  not  be  counted.  In  this  case  every  available  cutaneous 
vein  in  the  body  had  been  used  for  saline  infusion.  Localized  abscesses 
in  various  parts  of  the  abdominal  cavity  are  not  infrequent  during 
convalescence  from  a  diffuse  peritonitis.  Their  presence  is  indicated 
by  an  acute  rise  in  temperature  and  pulse,  a  high  leukocytosis,  pros- 
tration, and  the  occurrence  of  sweats.  The  tenderness  may  be  slight 
even  in  large  collections  of  pus,  and  should  carefully  be  sought  for 
by  abdominal  palpation,  vaginal  or  rectal  examination.  The  symp- 
toms will  promptly  subside  as  soon  as  the  focus  is  located  and 
adequately  drained. 

Sequelae  of  Acute  Appendicitis. — Infection  from  an  inflamed  ap- 
pendix may  extend  along  the  retroperitoneal  lymphatics  to  the  under 
surface  of  the  diaphragm,  giving  rise  to  subphrenic  abscess;  or  it  may 
extend  upward  from  the  radicles  of  the  portal  vein  to  the  liver,  and 
as  a  result  we  may  have  a  septic  portal  thrombosis  with  multiple  ab- 
scesses of  the  liver  and  pyemia.  Gerster  and  Munro  have  recently 
called  attention  to  these  conditions,  which  are  not  infrequent  even 
after  early  operation  and  apparent  subsidence  of  the  septic  manifes- 
tations. These  complications  would  be  favored  by  a  rupture  of  the 
appendix  and  the  formation  or  an  abscess  between  the  two  layers  of 


APPENDICITIS  509 

its  mesentery.  The  treatment  of  these  conditions  will  be  considered 
elsewhere. 

Fecal  fistula    not   infrequently    follows   appendicitis,   especially    if 

the  appendix  and  cecum  are  greatly  infiltrated  and  surrounded  by 
an  abscess.  In  these  cases  removal  of  the  appendix  may  result  in 
injury  to  the  wall  of  the  gut,  and  a  ligature  placed  around  the  stum}) 
may  cut  through  before  it  is  tightened  sufficiently  to  occlude  the 
lumen  of  the  tube.  Under  these  conditions  a  fistula  often  may  be 
prevented  by  drawing  a  piece  of  omentum  over  the  stump  and  suturing 
it  to  the  cecal  wall.  The  treatment  of  fecal  fistula  consists  in  cleanliness 
and  frequent  dressings.  Drainage  should  be  removed  as  soon  as  the 
sinus  is  sufficiently  organized  to  remain  patent,  and  the  opening 
allowed  to  heal  by  granulation.  The  great  majority  of  these  cases 
heal  spontaneously.  - 

Ventral  hernia  frequently  follows  operations  for  acute  appendi- 
citis, especially  if  the  wound  is  allowed  to  remain  open  for  drainage. 
The  treatment  is  the  same  as  for  other  varieties  of  postoperative 
ventral  hernia. 

Congenital  Idiopathic  Dilatation  of  the  Colon  (Hirschsprung's 
Disease). — This  rare  condition,  as  the  name  implies,  consists  of  a 
chronic  dilatation  of  the  sigmoid  and  often  of  the  greater  part  of  the 
transverse  and  descending  portions  of  the  colon,  resulting  in  an 
enormous  accumulation  of  fecal  matter  and  gas  (Fig.  286). 

The  cause  of  the  condition  is  by  no  means  clear.  Some  authorities 
hold  that  it  is  due  to  a  valvular  obstruction  in  the  upper  part  of  the 
rectum.  Others  that  it  is  due  to  some  fault  in  the  innervation  of  the 
gut,  which  results  in  a  limited  segment  being  without  the  power  of 
peristalsis;  while  others  ascribe  the  symptoms  to  an  increase  in  the 
length  of  the  sigmoid  or  its  mesentery.  Associated  with  the  dilatation 
there  is  nearly  always  a  decided  thickening  of  the  intestinal  wall 
which  involves  all  of  the  tunics. 

Symptoms. — Occasionally  children  are  born  with  the  condition 
already  present.  In  the  majority  of  instances,  however,  the  symptoms 
appear  shortly  after  birth. 

The  cardinal  symptoms  of  the  condition  are  obstinate  constipation 
and  a  progressive  distension  of  the  abdomen.  The  disease  may  ad- 
vance so  slowly  that  many  cases  reach  adolescence  or  adult  life  before 
serious  symptoms  develop.  The  distension  is  not  always  symmetric, 
being  noticed  more  on  the  left  side  and  lower  half  of  the  abdomen. 
The  stools  are  often  dry  and  hard;  sometimes  soft  and  very  offensive. 
Movements  occur  at  irregular  intervals,  and  only  after  repeated 
enemata  and  catharitics.  Visible  peristalsis  can  sometimes  be  seen. 
There  is,  as  a  rule,  no  ascites.  As  a  result  of  the  interference  with 
normal  nutrition,  the  patients  are  thin,  anemic,  and  weak.  Dyspnea, 
cardiac  weakness  and  irregularity  are  commonly  observed  when  the 
distension  is  excessive  and  the  diaphragm  pushed  upward. 


571 1 


hISEASES  OF   THE  ABDOMEX 


Prognosis. —The  disease  is  rarely  fatal.  In  a  few  cases  perforation 
has  occurred  with  fatal  peritonitis.  The  outlook  for  recovery,  however, 
i>  not  good  unless  the  condition  can  l»c  removed  by  surgical  operation. 

Treatment.  While  patients  may  he  kept  alive  for  an  indefinite 
period  by  the  judicious  use  of  cathartics,  enemata,  massage,  diet, 
and  hygienic  regulations,  these  have  absolutely  no  effect  on  the  patho- 
logic condition.  Finney  advises  colostomy  for  the  relief  of  the  acute 
condition;  later   a   lateral   entero-enterostoiny   above  and  below  the 


Fig.  2s6. — Megacolon. 

distended  portion,  and  at  a  still  later  period  resection  of  the  diseased 
area  of  the  colon.  Finney  has  recently  reported  a  successful  case 
operated  upon  by  this  method. 


DISEASES  OF  THE  LIVER. 

Ectopic  Liver. — The  liver  may  be  displaced  downward  in  a  condi- 
tion of  general  relaxation  of  the  abdominal  viscera  (Glenard's  disease). 


DISEASES  OF  THE  LIVER  .">71 

Hepatopexy,  or  suturing  the  liver  to  the  diaphragm  or  the  abdominal 
wall,  or  shortening  the  relaxed  ligaments,  lias  been  advised  to  remedy 

this  condition  when  it  gives  rise  to  sufficient  discomfort  to  warrant 
surgical  intervention,  but  the  results  are  disappointing. 

Abscess  of  the  Liver. — Abscess  of  the  liver  may  arise  from  trauma; 
from  infection  carried  to  the  organ  by  the  hepatic  artery  in  eases 
of  genera]  pyemia,  by  the  portal  vein  from  infections  processes  occur- 
ring in  the  regions  drained  by  the  portal  system,  as  appendicitis, 
dysentery,  typhoid  fever,  and  other  intra-abdominal  or  pelvic  diseases; 
or  from  the  biliary  passages,  as  in  cases  of  acute  infective  cholangitis. 
Hepatic  abscesses  may  be  single  or  multiple;  the  former  are  com- 
monly associated  with  dysentery,  especially  the  amebic  dysentery 
of  the  tropics,  and  in  over  80  per  cent,  of  the  eases  are  situated  in 
the  right  lobe.  The^e  amebic  abscesses  develop  very  slowly,  and 
often  are  not  recognized  until  months  or  years  have  elapsed  since  the 
colonic  infection.  Secondary  infection  may  take  place  at  any  time 
and  occasion  a  marked  change  in  the  clinical  picture,  by  substituting 
an  acute  septic  process  for  a  slowly  developing  cold  abscess.  When 
mixed  infection  is  absent,  these  abscesses  cpntain  a  reddish  or  pinkish 
pns  of  thick  gelatinous  consistence.  The  ameba?  are  rarely  found  in  the 
pus,  but  must  be  sought  in  the  scrapings  from  the  abscess  wall.  Another 
cause  of  solitary  hepatic  abscess  is  the  infection  by  the  blood  current 
of  a  pre-existing  hematoma  of  the  liver,  the  result  of  some  former* 
injury.  Multiple  abscesses  more  frequently  follow  appendicitis, 
suppuration  of  the  biliary  passages,  or  conditions  of  general  sepsis. 
Large  single  abscesses  may  result  from  a  coalescence  of  several  smaller 
foci.  They  may  reach  an  enormous  size,  and  not  infrequently  rupture 
into  the  peritoneal  or  pleural  cavity,  into  the  lung,  or  into  one  of  the 
hollow  viscera. 

Symptoms. — The  symptoms  of  hepatic  abscess  vary  greatly,  accord- 
ing to  the  virulence  of  the  infecting  agent  and  the  presence  or  absence 
of  a  condition  of  general  sepsis.  In  the  large  amebic  abseesses  the 
patient  may  complain  only  of  a  sense  of  discomfort  and  weight 
in  the  abdomen.  Associated  with  this  there  are  loss  of  flesh  and 
strength  and  generally  a  moderate  jaundice.  The  temperature 
may  remain  below  100°  F.,  and  the  pulse,  though  weak,  may 
not  be  rapid.  In  the  majority  of  instances,  however,  there  are 
pain  and  tenderness  over  the  region  of  the  liver,  with  fever,  chills, 
and  sweats.  The  patient  rapidly  emaciates  and  has  the  appearance 
of  profound  sepsis.  The  liver  is  enlarged  and  may  be  felt  as  an 
elastic  tumor  resembling  a  cyst.  Unless  there  is  a  mixed  infection, 
leukocytosis  is  not  present  in  amebic  abscess  of  the  liver.  In  ab- 
scesses due  to  pyogenic  bacteria  the  leukocyte  count  is  often  high. 
Rupture  of  the  abscess  into  the  peritoneum  or  pleural  cavity  would 
be  followed  by  symptoms  of  inflammation  of  these  structures.  If 
rupture  occurs  into  the  lung-tissue,  large  quantities  of  pus  may  be 
expectorated;  rupture  into  the  intestine  may  be  followed  by  rapid 


572  DISEASES  OF  THE  ABDOMEN 

relief  of  symptoms  and  ultimate  recovery.  In  multiple  abscesses  of 
the  liver  arising  either  from  portal  infection  or  an  acute  ascending 
cholangitis,  the  symptoms  are  those  of  a  grave  and  rapidly  progressing 
general  sepsis.  Local  symptoms  and  signs  may  be  absent  or  there  may 
be  pain  and  tenderness  over  the  hepatic  region,  with  mild  icterus.  One 
of  the  most  reliable  signs  is  the  occurrence  of  acute,  deep-seated  pain 
when  the  lower  segment  of  the  thorax  is  compressed.  In  these  cases  a 
fatal  issue  is  to  be  expected  in  the  great  majority  of  instances.  The 
use  of  an  aspirating-needle  for  purposes  of  diagnosis  is  not  to  be  recom- 
mended unless  one  is  prepared  to  operate  immediately  if  pus  is  found. 
In  certain  rare  instances  an  abscess  of  the  liver  may  give  rise  to  no 
localizing  symptoms  or  signs,  the  only  evidence  of  disease  being  the 
presence  of  continued  fever. 

Treatment. — A  liver  abscess  may  be  opened  and  drained  through 
the  anterior  abdominal  wall  or  through  the  back  by  a  transpleural 
operation.  Both  of  these  methods  are  dangerous  and  unsatisfactory 
unless  adhesions  are  present.  The  presence  of  adhesions  to  the  anterior 
abdominal  wall  would  be  indicated  by  edema  of  the  skin  and  sub- 
cutaneous tissues.  When  this  is  present,  an  incision  should  be  made 
through  the  tissues  to  the  liver,  which  may  then  be  aspirated,  and  if 
pus  is  found  an  opening  into  the  abscess  cavity  can  be  made  with 
the  cautery  or  some  blunt  instrument  and  a  drainage  tube  inserted.  If 
•no  adhesions  are  present,  the  abdomen  should  be  opened  over  the  en- 
larged Jiver,  and  if  the  symptoms  are  not  too  urgent,  the  parietal 
peritoneum  may  be  stitched  to  the  surface  of  the  liver,  the  wound 
packed  with  gauze,  and  the  opening  into  the  abscess  deferred  until 
adhesions  have  formed  shutting  off  the  general  peritoneal  cavity. 

If  the  case  is  urgent  and  rupture  is  feared,  the  surrounding  peritoneal 
cavity  should  be  packed  with  large  masses  of  gauze,  the  parietes 
pressed  firmly  down  upon  the  surface  of  the  liver,  and  the  abscess 
cavity  opened.  The  pus,  if  present  in  large  amount,  should  be  removed 
by  means  of  a  suction  apparatus,  the  cavity  disinfected  with  hydrogen 
peroxide  and  firmly  packed  with  gauze,  the  end  of  which  emerges 
through  the  abdominal  incision.  The  abdominal  packing  is  then 
removed  and  the  wound  partly  closed,  in  the  hope  that,  by  the  time 
it  is  necessary  to  remove  the  gauze  from  the  abscess  cavity,  adhesions 
will  have  formed  and  contamination  of  the  general  cavity  be  avoided. 
If  the  abscess  cavity  is  demonstrated  by  aspiration  to  lie  posteriorly 
near  the  pleural  sac,  a  portion  of  the  eighth,  ninth,  or  tenth  rib 
may  be  resected,  the  parietal  pleura  stitched  to  the  diaphragm,  and 
the  abscess  opened  immediately;  or,  if  possible,  the  wound  should  be 
packed  for  forty-eight  hours  and  the  opening  made  after  adhesions 
have  formed.  Mayo  recommends,  in  suturing  the  parietal  pleura  to 
the  diaphragm,  that  a  few  layers  of  sterile  gauze  be  laid  over  the  area 
to  be  sutured  and  the  stitches  taken  through  this  pad.  After  adhesions 
have  formed  the  incision  is  made  directly  through  the  gauze.  In  about 
GO  per  cent,  of  solitary  abscesses  of  the  liver  the  pus  is  sterile.    In  these 


TUMORS  OF   THE  LIVER  573 

cases  the  prognosis  is  favorable;  in  the  more  virulent  cases  the  outlook 
is  grave. 

There  is  no  surgical  treatment  for  multiple  abscesses  of  the  liver, 
except  to  open  and  drain  the  large  collections  as  they  are  found. 


TUMORS  OF  THE  LIVER. 

Hydatid  Cysts. — These  tumors  occur  more  frequently  in  the  liver 
than  in  any  other  organ  of  the  body.  They  may  be  single  or  multiple, 
and  may  reach  an  enormous  size.  The  fluid  contained  in  a  hydatid 
cyst  is  clear  or  slightly  opalescent,  of  low  specific  gravity,  contains  a 
trace  of  salt  but  no  albumin;  scolices  or  hooklets  can  be  found  by  the 
microscope.  If  the  cysts  are  small  and  deeply  seated  in  the  liver,  they 
produce  no  symptoms.  If  larger,  they  produce  an  enlargement  of  the 
organ  and  give  rise  chiefly  to  symptoms  of  pressure.  If  larger  still 
and  situated  near  the  surface,  the  globular  outline  may  often  be  made 
out  and  fluctuation  sometimes  determined.  Hydatid  fremitus  oc- 
casionally may  be  detected  by  palpation  if  the  cyst  lies  close  to  the 
abdominal  wall.  It  is  supposed  to  be  caused  by  a  rubbing  together 
of  the  daughter  cysts,  and  is  appreciated  by  applying  the  palm  of 
the  hand  to  one  part  of  the  tumor  and  sharply  percussing  the  mass  at 
another  point.  It  is  rarely  observed  in  cases  where  the  amount  of 
fluid  is  large.  Santoni  advises  auscultatory  percussion  in  these  cases, 
and  describes  a  characteristic  sound  of  low,  sonorous  quality,  which 
ceases  abruptly.  Thomas  Fiaschi,  of  Sidney,  Australia,  whose  ex- 
perience in  hydatid  disease  is  very  large,  has  verified  Santoni's  ob- 
servation and  regards  this  sound  as  of  considerable  diagnostic  impor- 
tance. If  suppuration  occurs  in  one  of  the  cysts,  there  will  be  pain, 
fever,  chills,  sweats,  and  prostration. 

Treatment. — Aspiration  is  to  be  avoided  on  account  of  the  danger 
of  infecting  the  peritoneal  cavity;  for  it  has  been  demonstrated  that 
each  of  the  parasitic  elements  is  capable  of  reproducing  the  lesion. 
The  disease  may  be  treated  in  four  ways:  complete  removal  of  the 
cyst  with,  if  necessary,  excision  of  a  portion  of  the  liver;  emptying 
the  cyst,  removal  of  the  endocyst,  and  stitching  the  ectocyst  to  the 
cutaneous  margin  (marsupialization) ;  removal  of  the  endocyst  and 
closing  the  abdominal  cavity,  allowing  the  ectocyst  to  drain  into  the 
peritoneum;  marsupialization,  without  removal  of  the  endocyst,  and 
the  subsequent  employment  of  solutions  of  formalin,  nitrate  of  silver 
or  iodine  to  render  the  sac  and  the  remaining  daughter  cysts  sterile. 
Quenu  suggests  aspiration  of  the  cyst,  and  subsequent  refilling  with 
a  1  per  cent,  solution  of  formalin,  which  is  allowed  to  remain  for  at 
least  five  minutes.  This  absolutely  sterilizes  the  cyst  contents,  and 
allows  the  operation  of  removal  to  take  place  with  less  danger  of 
peritoneal  infection.  Spontaneous  recovery  occasionally  occurs  from 
death  of  the  organism.    This  may  be  favored,  as  suggested  by  Fiaschi, 


574  DISEASES   OF    THE   A  EDO  MEN 

by  the  internal  administration  of  nrotropin.  In  these  eases  the  cyst 
shrinks,  and  finally  contains  only  a  small  mortar-like  mass. 

Solid  Tumors.  —  Angiomata,  adenomata,  sarcomata,  and  carcin- 
omata  occur  primarily  in  the  liver.  Small  cavernous  nevi  are  not 
infrequently  found  on  autopsy.  They  give  rise  to  no  symptoms  and 
are  of  no  particular  surgical  interest. 

Adenomata  may  grow  to  the  size  of  a  small  apple.  They  appear  as 
greenish  or  whitish  firm  tumors,  and  rarely  give  rise  to  any  symptoms 
or  disturbance  of  function. 

Primary  carcinoma  of  the  liver,  which  is  rare,  may  occur  in  two 
forms,  one  as  a  group  of  hard,  whitish  nodules,  commonly  situated 
in  the  neighborhood  of  the  portal  fissure;  the  other  as  a  diffuse 
carcinomatous  infiltration  of  the  entire  gland.  Secondary  carcinoma 
and  sarcoma  of  the  liver  are  of  frequent  occurrence,  the  former  follows 
most  frequently  breast  cancer,  or  disease  situated  in  the  portal  area, 
the  latter  may  result  from  sarcoma  in  any  part  of  the  body.  While 
the  diagnosis  of  primary  malignant  disease  of  the  liver  is  rarely  made 
at  a  period  when  operative  treatment  could  hold  out  any  prospect  of 
cure  or  even  justifiable  palliation,  it  occasionally  happens  that  an 
exploratory  laparotomy  will  reveal  the  early  stage  of  a  malignant 
growth,  situated  in  a  favorable  position  for  removal. 

Symptoms. — The  symptoms  of  sarcoma  or  carcinoma  are  a  marked 
but  painless  enlargement  of  the  liver,  which  presents  a  hard  nodular 
surface;  jaundice,  ascites,  anemia,  and  progressive  loss  of  flesh  and 
strength.  While  malignant  disease  of  the  liver  has,  in  the  past,  been 
regarded  as  an  absolutely  hopeless  condition,  the  successful  operations 
by  Lin,  Keen,  Cullen,  and  many  others  have  demonstrated  that  the 
resection  of  large  areas  of  liver  substance  is  not  only  technically 
possible,  but  is  actually  accomplished,  with  a  comparatively  low  death- 
rate.  This  fact  has  encouraged  surgeons  to  advise  and  practice  removal 
in  the  early  stage,  of  primary  malignant  growths  of  the  liver,  when 
located  in  an  accessible  position.  The  technic  of  the  operation  will 
be  described  later  in  the  chapter. 

Gummata. — Gummata  of  the  liver  occur  with  considerable  fre- 
quency. Although  not  a  surgical  condition,  they  give  rise  frequently 
to  symptoms  strongly  suggesting  surgical  disease  of  the  gall-bladder 
and  ducts.  These  symptoms  are  pain,  localized  tenderness,  and 
muscular  rigidity  in  the  upper  right  quadrant  of  the  abdomen,  with 
jaundice  and  occasionally  the  presence  of  a  tumor.  The  author 
lias  on  three  occasions  opened  the  abdomen  for  treatment  of  a  supposed 
cholecystitis,  and  found  the  lesion  to  be  gumma  of  the  liver;  in  one 
case  more  or  less  general,  in  two  localized  near  the  gall-bladder.  In 
these  doubtful  cases  the  Wassermann  reaction  will  be  of  posith  e  value. 

The  Surgical  Treatment  of  Ascites  due  to  Cirrhosis  of  the  Liver  — 
The  ascites  of  cirrhosis  of  the  liver  is  generally  believed  to  be  due 
to  obstruction  of  the  portal  circulation.  Spontaneous  cure  has  very 
rarely  occurred,  and  in  these  cases  a  subsequent  autopsy  has  demon- 


DISEASES  OF  THE  BILIARY  PASSAGES  575 

strated  adhesions  and  vascular  connection  between  the  liver,  omentum, 
spleen,  and  intestines,  and  the  diaphragm  and  anterior  abdominal 
wall,  allowing  the  blood  from  the  portal  system  to  gain  entrance  to 
the  general  circulation  without  passing  through  the  contracted  liver. 
Talma  and  Rutherford  Morison  each  conceived  the  idea  of  favoring 
nature's  methods  in  these  cases  by  creating  adhesions  by  surgical 
procedures. 

Morison's  operation  consists  in  making  a  median  incision  through 
the  abdominal  wall,  opening  the  peritoneal  cavity,  and  evacuating 
the  fluid.  The  upper  surface  of  the  liver  is  then  rubbed  with  a  pledget 
of  gauze  until  a  raw  bleeding  surface  is  produced,  and  the  adjacent 
surface  of  the  diaphragm  is  treated  in  the  same  manner.  The  same 
procedure  is  next  carried  out  on  the  external  surface  of  the  spleen 
and  its  adjacent  parrietal  peritoneum,  after  which  the  omentum  is 
stitched  to  the  anterior  abdominal  wall,  the  peritoneal  surface  of  which 
has  been  similarly  freshened.  The  abdominal  wall  is  then  sutured, 
and  a  glass  drain  introduced  into  the  pelvic  cavity  through  a  separate 
incision  just  above  the  pubis,  through  which  the  accumulating  fluid 
is  removed  by  gauze  suction  three  or  four  times  a  day  until  fluid 
ceases  to  be  secreted. 

Morison  obtained  two  cures  of  ascites  by  this  method,  and  since 
that  time  several  other  favorable  results  have  been  obtained.  A 
review1  of  all  the  cases  reported  in  the  journals  during  five  years 
was  made  by  the  writer,  which  showed  a  mortality  of  37  per  cent., 
with  10  per  cent,  of  cures  and  20  per  cent,  of  marked  improvement. 
Greenough  subsequently  collected  105  operations  which  showed  a 
death-rate  of  about  30  per  cent,  and  less  than  10  per  cent,  of  cures. 
Xarath  and  others  have  modified  the  operation  with  a  view  to  lowering 
the  mortality.  At  present  most  surgeons  simply  evacuate  the  fluid, 
implant  a  portion  of  the  omentum  between  the  peritoneum  and  the 
rectus  muscles,  close  the  abdomen  tightly,  and  depend  upon  sub- 
sequent tappings  to  remove  the  fluid  which  accumulates  while  the 
adhesions  are  being  formed.  The  operative  risk  from  this  procedure 
is  low.  As  experience  has  shown  that  these  cases  almost  invariably 
die  within  a  few  months  after  the  appearances  of  the  ascites,  the  results 
of  the  operation  would  seem  to  warrant  its  continued  trial. 

DISEASES  OF  THE  BILIARY  PASSAGES. 

Cholelithiasis. — Cholelithiasis,  or  the  presence  of  gallstones  in  the 
biliary  passages,  is  of  frequent  occurrence;  according  to  Reidel  and 
Kehr,  they  are  found  in  10  per  cent,  of  all  adult  autopsies.  Gall- 
stones are  composed  of  crystals  of  cholesterin  and  lime  salts,  held 
together  by  mucus  and  colored  by  bile-pigment.  They  may  occur 
singly  or  in  any  number.     They  may  be  rough,  oval,  or  irregular 

1  The  Surgical  Treatment  of  Ascites  Due  to  Cirrhosis  of  the  Liver,  Medical  News, 
February  8,  1902. 


576 


DISEASES  OF   THE  ABDOMEN 


in  outline,  and  of  a  dirty-brown  color;  or,  more  commonly,  they 
are  found  to  be  smooth,  faceted,  and  of  a  yellowish  satin-like  lustre. 
Two  elements  are  essential  for  the  formation  of  gallstones,  stasis  or 
a  sluggish  flow  of  bile,  and  infection.  The  former  is  brought  about  by 
a  sedentary  life,  over  indulgence  in  food,  a  relaxed  abdominal  wall, 
and  obesity;  the  latter  by  some  subacute  infection,  generally  located 
in  the  portal  area.  Pathogenic  organisms  are  carried  from  this  focus 
to  the  liver  by  the  portal  vein,  excreted  in  the  bile,  and  thus  enter 
the  gall-bladder.  Here  they  occasion  a  mild  infection  of  the  mucous 
membrane,  giving  rise  to  the  secretion  of  a  changed  mucus  which 
acts  as  a  cement  substance  and  binds  the  precipitated  crystals  of 


Fig.  287. — Radiograph  of  gallstones. 

cholesterin  together.  Exceptionally,  biliary  concrements  may  form 
in  the  bile  ducts;  these  are  generally  softer,  darker  in  color,  lustreless, 
and  appear  to  be  composed  of  inspissated  bile.  The  writer  has  once 
seen  the  gall-bladder  and  cystic  duct  completely  filled  with  this 
material,  which  had  the  consistency  of  putty. 

Gallstones  may  occur  at  any  age,  but  they  are  commonest  in 
adults,  and  are  more  frequent  in  women  than  in  men.  Sedentary 
habits,  overeating,  and  digestive  disturbances  act  as  predisposing 
factors.  The  frequent  association  of  cholelithiasis  with  typhoid  fever 
has  led  to  much  bacteriological  investigation  of  gallstones.  This 
has  resulted  in  the  demonstration  in  the  calculi  not  only  of  typhoid 
bacilli,  but  of  many  other  organisms  mostly  of  the  colon  group. 


PLATE  XIX 


Cholelithiasis  with  Cholecystitis. 

Lumiere  plate  of  specimen   taken  from  patient  in  author's  service  at  the 

Roosevelt  Hospital. 


DISEASES  OF  THE  BILIARY  PASSAGES  577 

Symptoms. — Kehr  stated  some  years  ago  that  in  95  per  cent,  of  the 
cases,  gallstones  produced  no  symptoms.  At  that  time  only  the 
complication  of  cholelithiasis  were  recognized  by  their  symptom- 
atology, for  colic,  fever,  jaundice,  tenderness  and  abscess  formation 
are  now  known  to  be  due  to  the  transit  of  stones  from  the  gall-bladder 
to  the  ducts  or  intestine,  to  biliary  obstruction,  or  infection. 

That  the  presence  of  gallstones  in  an  uninfected  gall-bladder  often 
can  be  recognized  by  a  group  of  characteristic  symptoms  is  now 
generally  accepted.  Moynihan  has  designated  these  as  the  "inaugural 
symptoms"  of  cholelithiasis.  They  differ  entirely  from  those  due  to 
the  passage  of  a  stone  to  the  intestine  or  its  arrest  in  one  of  the  ducts, 
and  are  largely  digestive  in  character,  often  simulating  mild  cases  of 
ulcer  or  the  vague  upper  abdomen  sensations  of  chronic  appendicitis. 
Slight  distress  or  fulness  after  meals,  gas  distension,  and  eructations 
are  perhaps  the  earliest.  Later  epigastric  pain,  radiating  to  the  back, 
pyrosis,  transitory  sensations  of  chilliness,  especially  after  the  evening 
meal,  waves  of  slight  nausea,  and  an  occasional  "catch  in  the  breath" 
with  a  sharp  stabbing  pain  at  the  costal  border,  are  all  more  or  less 
characteristic  of  cholelithiasis;  and  when  associated  with  Murphy's 
sign  or  a  sudden  pain  on  inspiration  when  the  thumb  is  pushed  beneath 
the  right  costal  arch  at  the  outer  border  of  the  rectus  muscle,  they 
render  the  diagnosis  of  gallstones  highly  probable,  although  one 
would  hardly  be  justified  in  making  a  more  positive  statement. 

When  a  gall-stone,  of  sufficient  size  to  completely  fill  the  cystic 
duct,  begins  its  transit  to  the  intestine,  or  when  such  a  stone  by  tem- 
porary impaction  causes  a  backing  up  of  the  bile  and  distension  of  the 
bladder,  pain  is  produced  of  a  severe  colicky  character,  often  radiating 
to  the  back  and  shoulder.  This  pain  at  times  becomes  so  severe  that 
morphine  in  large  doses  is  required  for  its  relief.  With  the  pain  often 
there  is  vomiting,  localized  tenderness,  and  great  restlessness,  but  no 
fever.  These  attacks  of  gallstone  colic  often  continue  for  several 
hours  and  then  suddenly  cease,  due  to  the  passage  of  the  stone  into 
the  intestine  or  to  the  dropping  back  into  the  gall-bladder  of  a  stone 
arrested  at  the  beginning  of  the  cystic  duct.  If  the  stone  becomes  per- 
manently impacted  in  the  cystic  duct,  causing  complete  obstruction, 
the  pain  gradually  subsides,  and  there  follows  a  slow  painless  distention 
of  the  gall-bladder  which  is  easily  palpable  (hydrops).  These  gall- 
bladders may  reach  a  large  size  and  are  not  infrequently  mistaken 
for  ovarian,  hydatid,  or  other  large  abdominal  cysts.  The  fluid 
contents  in  the  later  stages  showr  no  trace  of  bile,  only  a  thin  cloudy 
or  opalescent  mucus.  Sometimes  the  stone  become  arrested  between 
two  strictures  in  the  cystic  duct  without  marked  obstruction.  In 
these  cases  the  attacks  of  colic  occur  frequently,  often  every  day, 
are  usually  less  severe  and  of  shorter  duration.  There  is  no  jaundice, 
and  fever  is  rarely  present. 

When  a  gallstone  is  arrested  in  the  common  duct,  jaundice  appears. 
The  point  at  which  stones  usually  become  arrested  is  at  the  papilla 
37 


578  DISEASES  OF   THE  ABDOMEN 

where  the  duct  opens  into  the  duodenum.  Occasionally  impaction 
at  this  point  becomes  permanent,  when  a  progressively  increasing 
jaundice  occurs  with  a  gradually  lessening  pain.  The  jaundice  at  first 
bright  orange-yellow,  gradually  becomes  darker,  and  as  the  cholemia 
advances  the  color  may  become  green,  brown,  or  almost  black.  The 
stools  are  clay-colored,  the  urine  dark  from  the  presence  of  bile,  and 
a  distressing  itching  of  the  skin  is  present.  There  is  a  rapid  loss 
of  flesh,  and  a  tendency  to  intestinal  hemorrhages.  In  the  majority 
of  cases,  however,  a  common  duct  stone  will  remain  impacted  at  the 
papilla  for  a  short  time  only,  then  will  be  released  by  the  resulting 
distension  of  the  duct.  This  will  allow  it  to  pass  into  the  intestine 
or  to  float  upward  in  the  dilated  duct,  with  relief  of  all  symptoms 
until  it  again  becomes  impacted  at  the  papilla.  This  latter  condition 
of  "floating  stone  in  the  common  duct"  is  associated  with  a  very 
characteristic  group  of  symptoms.  There  are  intermittent  pain, 
intermittent  fever,  and  intermittent  jaundice.  Often  the  fever  is 
high,  and  accompanied  by  chills  and  sweats;  a  condition  somewhat 
resembling  malaria,  to  which  Charcot  gave  the  name  fievre  inter- 
mittent hSpatique. 

The  fever  and  other  septic  manifestations  in  these  cases,  is  generally 
due  to  an  infective  cholangitis,  the  infectious  material  gaining  entrance 
to  the  duct  through  the  damaged  papilla.  Larger  stones  not  infre- 
quently ulcerate  through  the  gall-bladder  or  ducts,  into  the  stomach 
or  intestine,  and  may  later  become  arrested  in  the  bowel.  This 
occasionally  occurs  without  recognizable  symptoms,  and  the  first 
indication  of  the  process  may  be  signs  of  intestinal  obstruction. 

One  of  the  rarer  complications  of  cholelithiasis  is  acute  pancreatitis. 
This  may  be  caused  by  the  arrest  of  a  small  stone  at  the  orifice  of  the 
papilla,  allowing  septic  bile  to  regurgitate  into  the  canal  of  Wirsung, 
giving  rise  to  an  acute  suppurative  or  gangrenous  pancreatitis.  More 
frequently  however,  sepsis  of  a  lower  grade  enters  the  pancreas  by 
this  route,  or  through  the  lymphatic  connections  of  the  pancreas 
with  the  biliary  passages,  which  results  in  an  edema,  or  chronic  inter- 
stitial pancreatitis  largely  confined  to  the  head  of  the  organ.  This 
by  exciting  pressure  on  the  common  duct  may  be  the  cause  of  continued 
jaundice,  after  the  stone  has  passed  or  been  removed. 

Of  all  the  complications  of  cholelithiasis,  the  commonest  is  sepsis. 
This  may  occur  in  the  gall-bladder,  giving  rise  to  cholecystitis  of  vary- 
ing degrees,  or  in  the  ducts  causing  cholangitis.  These  inflammatory 
conditions  will  be  described  at  length  in  a  subsequent  section. 

Prognosis. — The  presence  of  gallstones  in  the  gall-bladder  or  ducts 
is  undoubtedly  a  menace  to  the  future  health  of  the  individual.  While 
many  individuals  carry  gallstones  throughout  a  long  life  without 
apparent  discomfort  or  serious  consequences,  complications  are  liable 
at  any  time  to  arise,  placing  health  or  life  in  jeopardy.  All  surgeons 
of  experience  recognize  that  removal  of  biliary  calculi  before  infection 
occurs  and  before  common  duct  obstruction  is  present,  is  a  compara- 


DISEASES  OF  THE  BILIARY   PASSAGES  579 

tively  safe  precautionary  measure,  and  is  to  be  advised  when  the 
condition  of  the  patient's  health  and  surroundings  is  favorable. 

Acute  cholecystitis  with  the  possibility  of  perforation,  suppurative 
cholangitis,  especially  when  complicated  by  cholemia,  and  suppurative 
or  gangrenous  pancreatitis,  are  serious  conditions  associated  with  a 
high  mortality,  and  operations  undertaken  under  these  circumstances, 
are  attended   by  grave  risks. 

Treatment. — Cholelithiasis  is  a  surgical  disease.  Medical  treatment 
is  of  no  avail  except  to  palliate  the  distressing  symptoms  during  an 
attack.  A  course  at  Carlsbad  occasionally  will  relieve  the  catarrhal 
condition  of  the  gall-bladder  and  ducts,  but  no  known  remedial  agent 
has  the  power  to  dissolve  gallstones.  During  an  attack  of  colic,  a 
hot  bath,  hot  stupes,  and  morphine  are  indicated,  and  will  often 
hasten  the  period  of  relief.  Regular  exercise,  the  avoidance  of  rich 
food  and  alcoholic  drinks  are  of  value  as  prophylactic  measures,  but 
when  an  individual  once  beings  to  suffer  from  gallstone  disease,  the 
surgeon  should  be  consulted. 

Cholecyst ostomy  with  removal  of  stones  is  the  operation  of  choice 
in  cases  of  biliary  calculi  limited  to  the  gall-bladder,  when  no  infection 
is  present  and  when  the  ducts  are  free.  When  cholecystitis  is  present 
or  when  the  contractility  of  the  gall-bladder  has  been  lost  as  a  result 
of  former  infection,  when  the  cystic  duct  is  strictured,  or  the  seat  of 
ulceration,  which  renders  subsequent  stricture  and  obstruction  prob- 
able, cholecystectomy  is  to  be  advised.  In  cases  of  stone  in  the 
common  duct,  cholecodotomy  with  hepaticus  drainage  is  indicated. 
When  the  stone  is  free  in  the  duct  or  impacted  in  its  upper  segment, 
the  incision  can  be  made  in  its  exposed  area,  above  the  head  of  the 
pancreas.  In  cases  of  impacted  stone  at  or  near  the  papilla,  exposure 
of  the  duct  by  a  turning  inward  of  the  duodenum  may  be  necessary, 
or  the  transduodenal  operation  may  be  undertaken,  removing  the 
stone  by  an  incision  through  the  duodenal  mucous  membrane.  In 
all  these  operations,  especially  in  late  neglected  cases,  a  generous 
incision  with  plenty  of  light  and  adequate  retraction  is  essential. 
Adhesions  are  frequently  present  rendering  exposure  of  the  parts 
difficult.  In  many  instances  adhesions  between  the  gall-bladder  and 
stomach  and  duodenum  are  the  result  of  old  fistulous  openings,  and 
care  should  be  taken  in  dividing  these,  not  to  infect  the  operative  area 
by  leakage  of  infected  bile  or  intestinal  matter,  before  the  wound  area 
is  adequately  protected. 

Rough  handling  of  the  viscera  in  the  upper  abdomen  is  always 
associated  with  a  high  degree  of  shock.  This  is  particularly  dangerous 
in  the  obese,  where  the  structures  are  deeply  seated  and  difficult  to 
expose,  and  where  the  individual  resistance  is  low. 

Cholecystitis. — Infection  may  reach  the  biliary  passages  by  several 
different  routes.  The  commonest  is  by  the  portal  circulation.  Bacteria 
gaining  entrance  to  the  portal  radicals  from  intestinal  appendicular 
or  pelvic  infections,  are  carried  to  the  liver.    Here  they  are  destroyed 


580  DISEASES  OF   THE  ABDOMEN 

by  the  bactericidal  action  of  that  organ  when  it  is  in  its  normal  con- 
dition. If  this  important  function  is  impaired  by  organic  disease  or 
the  functional  condition  described  as  torpid  or  sluggish  liver,  many  of 
these  bacteria  escape  death  and  are  excreted  in  the  bile.  Stasis  or  a 
sluggish  flow  of  bile  prevents  the  rapid  elimination  of  these  organisms 
from  the  gall-bladder  and  ducts,  and  if  the  resistance  of  these  organs 
is  still  further  reduced  by  the  constant  trauma  of  a  foreign  body 
as  a  gallstone,  an  infection  results  which  may  vary  in  intensity  from 
the  mildest  catarrhal  reaction  of  the  mucous  membrane,  to  an  acute 
fulminating  or  gangrenous  inflammation,  involving  all  the  structures 
of  the  gall-bladder  or  ducts. 

The  second  type  of  infection  is  the  ascending.  When  the  protective 
function  of  the  sphincter  at  the  intestinal  orifice  of  the  common  duct 
has  been  impaired  by  overstretching  from  the  passage  of  stones,  or 
by  ulceration  or  new  growth,  allowing  regurgitation  of  the  intestinal 
contents,  infection  may  ascend  along  the  ducts  and  enter  the  gall- 
bladder. The  other  and  less  frequent  routes  of  infection  are  by  the 
lymphatics,  the  arterial  blood  current,  and  by  direct  extension  from 
a  neighboring  focus,  as  gastric  or  duodenal  ulcer. 

Acute  cholecystitis  occurs  in  three  clinical  forms,  the  catarrhal,  the 
suppurative  and  the  gangrenous.  The  chronic  type  also  occurs  in  three 
forms:  the  thickened,  white,  inelastic  gall-bladder,  the  strawberry  and 
the  papillomatous  varieties. 

The  gross  changes  in  the  gall-bladder  in  cases  of  mild  catarrhal 
inflammation  are  insignificent.  "Where  the  process  is  more  active  the 
mucous  membrane  is  thickened,  the  peritoneal  coat  loses  its  normal 
blue  glistening  appearance,  and  an  excess  of  mucus  is  present  in  the 
bile.  In  the  severer  infections,  the  entire  organ  is  thickened,  red, 
edematous,  and  covered  with  fibrin.  The  mucous  membrane  is 
eroded  and  in  places  gangrenous,  the  bile  is  thick,  tarry,  and  mixed 
with  pus  and  mucus.  In  the  severest  types,  gangrene  and  perforation 
may  occur.  In  about  80  per  cent,  of  these  cases  stones  are  present. 
In  the  chronic  forms  the  appearances  vary  from  a  normal  shaped 
gall-bladder  with  slight  thickening,  and  opacity  of  the  peritoneum, 
to  a  dense  shrunken  fibrous  mass  containing  calculi  and  pus.  In 
certain  cases  of  chronic  cholecystitis  without  stones,  the  external 
appearance  of  the  organ  is  not  changed,  but  the  cavity  is  often  found 
to  be  filled  with  dark  colored  foul  smelling  pus.  In  these  cases  a 
careful  examination  of  the  mucous  membrane  will  reveal  a  reddened 
surface  studded  with  innumerable  yellow  points,  giving  rise  to  the 
term  "strawberry  gall-bladder."  The  yellow  points  are  minute 
bile-stained  erosions  on  the  summits  of  the  papillae.  In  certain  other 
cases  there  is  a  marked  hyperplasia  of  the  mucous  membrane  of  the 
papillomatous  type.  MacCarty  reports  microscopic  evidence  in  some 
of  these  cases  of  malignant  disease. 

Symptoms. — The  mildest  types  of  catarrhal  cholecystitis  are  symp- 
tomless, and  are  important,  only  in  that  they  result  in  gallstone 


PLATE    XX 


Acute  Cholecystitis. 

Lumiere  photograph  of  specimen  taken  from  patient  in  author's  service  at  the 

Roosevelt  Hospital. 


DISEASES  OF  THE  BILIARY  PASSAGES  581 

formation,  and  certain  mild  types  of  chronic  thickening  of  the  viscus. 
If  the  infecting  organism  is  more  virulent,  it  may  be  indicated  by  pain, 
tenderness,  fever,  and  the  presence  of  a  tumor  of  the  gall-bladder. 
In  a  mild  infection  of  the  organ  with  the  ducts  open,  insuring  free 
drainage  into  the  bowel,  these  symptoms  may  be  wanting. 

If  the  cystic  duct  becomes  obstructed  from  stone  or  swelling  of  the 
mucous  membrane,  colicky  pains  occur,  which  may  radiate  to  the 
back  and  shoulder;  vomiting  is  generally  present  during  the  period 
of  obstruction;  there  are  also  usually  slight  fever  and  general  malaise, 
which  disappear  with  the  pain  when  the  obstruction  is  relieved.  Unless 
the  gall-bladder  be  small  or  deeply  seated  under  the  right  lobe  of  the 
liver,  a  sensitive  tumor  may  be  felt  during  the  continuance  of  the 
obstruction.  These  symptoms  frequently  subside  spontaneously,  but 
the  tendency  to  recurrence  is  marked. 

If  chronic  obstruction  of  the  cystic  duct  occurs,  empyema  of  the 
gall-bladder  results,  giving  rise  to  symptoms  of  varying  severity 
according  to  the  virulence  of  the  infecting  agent  to  the  resistance  of 
the  individual.  The  pain  and  fever  may  be  wanting,  the  only  symp- 
toms being  the  presence  of  a  tender  tumor  in  the  gall-bladder  region; 
or,  in  cases  of  a  small  or  contracted  gall-bladder,  only  a  local  tenderness 
or  muscular  rigidity.  In  the  severer  cases  the  pain  is  acute,  paroxysmal, 
and  radiating;  the  fever  is  high,  and  is  accompanied  by  chills  and 
vomiting.  A  local  peritonitis  may  be  present,  a  condition  often 
resembling  appendicitis.  In  the  more  virulent  infections  the  symptoms 
often  develop  with  great  rapidity,  and  are  accompanied  by  marked 
prostration  and  a  rapidly  developing  sepsis.  Perforation  of  the  gall- 
bladder with  a  fulminating,  fatal,  septic,  general  peritonitis  has  been 
reported  in  a  number  of  instances.  Jaundice  is  absent  in  cholecystitis 
unless  the  tumor  of  the  gall-bladder  or  an  enlarged  lymph  node 
presses  upon  -the  common  duct. 

In  chronic  cholecystitis  with  or  without  stones,  the  symptoms  may 
be  simply  the  irregular  occurrence  of  acute  attacks,  with  no  discomfort 
or  only  slight  local  tenderness  between  them,  vague  digestive  disturb- 
ances, or  simply  the  evidences  of  a  mild  chronic  sepsis  as  a  subacute 
arthritis.  In  these  cases  the  gall-bladder  on  inspection  and  palpation 
often  appears  normal.  On  opening  the  viscus,  however,  changes  in  the 
character  of  the  bile,  and  in  the  appearance  of  the  mucous  membrane 
are  evident.  Enlarged  lymph  nodes  in  the  gastrohepatic  omentum 
along  the  cystic  and  common  ducts,  easily  palpable  when  the  abdomen 
is  opened,  may  often  indicate  the  opening  and  investigation  of  a  nor- 
mal appearing  gall-bladder,  in  the  presence  of  symptoms  pointing  to  a 
chronic  cholecystitis. 

Prognosis.- — Most  cases  of  acute  cholecystitis  will  subside  under 
appropriate  treatment,  the  pain,  temperature,  and  other  evidences 
of  infection,  showing  a  tendency  to  diminish  at  the  end  of  twenty-four 
or  forty-eight  hours.  A  persistence  of  high  fever,  tenderness  and 
muscular  rigidity,  and  a  progressively  increasing  leukocytosis,  indicate 


582  DISEASES  OF  THE  ABDOMEN 

a  suppurative  or  gangrenous  cholecystitis  or  an  extension  of  the 
process  to  the  surrounding  tissues.  Chronic  thickened  gall-bladders 
are  a  menace  to  the  individual,  and  should  be  removed,  particularly 
if  the  cystic  duct  is  strictured  or  occluded.  The  strawberry  gall-bladder 
is  frequently  the  source  of  a  chronic  sepsis  which  is  not  permanently 
relieved  by  drainage.  The  papillomatous  type  of  chronic  cholecystitis, 
occasionally  results  in  cancer. 

Treatment. — Mild  cases  of  cholecystitis  should  be  treated  by  rest 
and  an  ice-bag  to  the  tender  region  of  the  abdomen.  If  the  pain  is 
severe,  it  may  be  necessary  to  relieve  it  by  the  use  of  morphine  or  other 
forms  of  opium.  Although  the  gall-bladder  seldom  ruptures  spon- 
taneously, infection  of  the  peritoneal  cavity  may  rarely  occur  without 
rupture  and  lead  to  a  spreading  peritonitis  and  grave  sepsis.  For  this 
reason  operative  treatment  is  indicated  if  the  symptoms  do  not 
promptly  subside  as  a  result  of  the  treatment  outlined  above.  If 
the  cholecystitis  is  acute  and  the  ducts  are  patent,  cholecystostomy 
will  give  prompt  relief;  if  the  condition  is  a  chronic,  relapsing  one 
with  an  occluded  cystic  duct,  and  a  shrunken,  functionless  gall- 
bladder, cholecystectomy  is  to  be  recommended.  In  the  strawberry 
and  papillomatous  types  of  chronic  cholecystitis,  cholecystectomy  is 
indicated. 

Cholangitis. — An  inflammation  of  the  mucous  membrane  of  the  bile 
ducts,  particularly  of  the  common  and  hepatic. 

In  the  acute  type  which  is  practically  always  associated  with  the 
presence  of  stone  or  some  other  foreign  body  as  an  intestinal  worm, 
the  infection  "is  often  a  virulent  one,  extending  rapidly  to  the  intra- 
hepatic branches  giving  rise  to  multiple  abscesses  and  a  fatal  toxemia. 
In  other  cases  the  process  seems  to  be  limited  to  the  larger  ducts, 
and  although  marked  evidence  of  septic  absorption  may  be  present, 
especially  when  drainage  into  the  intestine  is  interfered  with,  the 
condition  may  exist  for  months  or  years  without  the  development 
of  fatal  hepatic  lesions. 

An  exceedingly  mild  type  of  the  affection  is  often  described,  which 
is  thought  to  be  an  ascending  process  from  the  duodenum  without 
known  cause,  or  the  presence  of  any  pathological  process  in  the  gall- 
bladder or  ducts. 

This  subacute  cholangitis  is  supposed  to  be  the  cause  of  the  so-called 
"catarrhal  jaundice." 

As  the  association  of  this  lesion  with  transitory,  afebrile  and  symp- 
tomless jaundice  has  not  been  demonstrated,  the  majority  of  surgeons 
now  accept  the  view  of  Robson  that  the  causation  of  most  cases  of 
catarrhal  jaundice  is  to  be  found  in  a  temporary  closure  of  the  common 
duct  from  the  pressure  of  a  lymphatic  edema  or  subacute  inflammation 
of  the  head  of  the  pancreas. 

Symptoms. — Acute  cholangitis  occurs  most  frequently  in  cases  of 
common  duct  stone,  particularly  in  the  type  described  as  floating 
stone.    These  cases  present  a  very  characteristic  group  of  symptoms. 


TUMORS  OF   THE  GALL-BLADDER  AND  DUCTS  583 

When  duct  occlusion  occurs  from  temporary  impaction  of  the  stone, 
at  the  papilla,  there  will  occur  a  chill  followed  by  high  fever,  colic, 
increased  jaundice,  and  often  sweating.  All  of  these  symptoms  are 
relieved  when  the  stone  floats  upward  and  drainage  is  established. 
These  attacks  occur  at  irregular  intervals  and  their  duration  is  gener- 
ally short.  When  the  period  of  obstruction  is  of  longer  duration,  or 
when  the  virulence  of  the  infection  is  high,  the  type  of  symptoms 
changes  to  that  of  a  rap'dly  advancing  septic  intoxication,  continued 
high  fever,  chills,  a  rapid  feeble  pulse,  high  leukocytosis  with  pro- 
gressive jaundice,  prostration,  delirium,  and  death. 

In  certain  rare  cases  the  attacks  occur  at  longer  intervals,  several 
days  or  weeks  may  elapse  during  which  the  patient  is  free  from  all 
symptoms  or  discomfort.  In  these  cases  the  condition  may  exist  for 
many  months  or  even  years,  the  patient  gradually  deteriorating  in 
health  and  presenting  the  evidences  of  chronic  invalidism. 

Prognosis. — The  prognosis  in  acute  septic  cholangitis  is  grave.  In 
the  more  virulent  cases  the  course  is  rapid  toward  a  fatal  termination 
unless  promptly  relieved  by  operation.  In  the  less  virulent  cases,  the 
outlook  is  also  serious,  for  the  possibility  of  relief  by  the  spontaneous 
passage  of  the  stone  is  exceedingly  remote,  and  until  adequate  drainage 
is  secured  permanent  improvement  is  not  to  be  expected. 

Treatment. — As  soon  as  the  diagnosis  of  acute  septic  cholangitis 
is  made,  the  indications  are  for  operation.  Choledochotomy,  removal 
of  the  stone,  and  hepaticus  drainage. 

TUMORS  OF  THE  GALL-BLADDER  AND  DUCTS. 

While  new  growths  of  neighboring  organs  not  infrequently  produce 
symptoms  referable  to  the  gall-bladder  or  ducts  by  external  press- 
ure or  direct  extension,  primary  new  growths  in  these  organs  are 
exceedingly  rare. 

The  gall-bladder  is  most  frequently  affected,  and  in  the  great 
majority  of  instances  the  growth  is  malignant. 

Carcinoma  of  the  Gall-bladder  was  observed,  according  to  Cour- 
voisier,  in  7  in  2520  autopsies.  Three-fourths  of  the  cases  occur  in 
women.  The  relationship  between  cholelithiasis  and  cancer  of  the 
gall-bladder  is  evidenced  by  the  fact  that  in  95  per  cent,  of  primary 
cancer  cases  stones  are  present,  while  in  the  secondary  carcinomata 
of  this  organ  calculi  are  found  in  only  15  per  cent.  As  in  the  case  of 
ulcer  of  the  stomach,  chronic  irritation  gives  rise  to  an  inflammatory 
process  with  epithelial  proliferation  which  eventually  results  in  cancer. 
MacCarty  of  the  Mayo  Clinic  has  recently  published  the  report  of 
some  pathological  studies  in  these  cases,  and  has  been  able  to  obtain 
convincing  evidence  of  the  fact  that  chronic  papillomatous  colecystitis 
not  infrequently  degenerates  into  cancer. 

Symptoms. — There  are  no  early  characteristic  symptoms  of  gall- 
bladder cancer.     Symptoms  and  signs  of  stone  or  the  associated 


584  DISEASES  OF   THE  ABDOMEN 

cholecystitis  may  or  may  not  be  present,  and  not  infrequently  vague 
digestive  disturbances,  and  loss  of  weight  and  strength  may  be  noted 
before  any  signs  of  the  disease  are  manifest.  Tumor,  in  the  great 
majority  of  cases,  is  the  first  sign,  and  is  often  discovered  by  accident 
or  as  a  result  of  a  systematic  abdominal  examination.  Later  there  may 
be  pain,  vomiting,  anorexia,  and  jaundice.  This  last  symptom  with 
ascites  and  splenic  enlargement,  are  to  be  regarded  as  terminal  symp- 
toms and  are  due  to  the  pressure  of  involved  lymph  nodes  on  the  portal 
vein  and  common  duct. 

Prognosis. — The  outlook  in  cases  of  gall-bladder  cancer  is  exceed- 
ingly grave,  hopeless  in  fact,  if  operation  is  not  undertaken  until  the 
diagnosis  is  made  probable  by  the  clinical  signs.  In  53  such  cases 
operated  upon,  death  followed  in  every  instance  within  nine  months 
(Courvoisier).  In  cases  discovered  at  an  earlier  period,  as  a  result  of 
an  exploratory  laparotomy,  the  prognosis  is  more  favorable,  two  out 
of  five  such  cases  were  reported  from  the  Mayo  Clinic  to  be  alive, 
and  free  from  recurrence  at  the  end  of  two  years. 

Tumors  of  the  Bile  Ducts. — Both  benign  and  malignant  tumors 
occur  in  the  gall  ducts. 

Carcinoma.— Carcinoma  of  the  ducts  is  a  rare  disease.  About  one 
case  to  six  of  cancer  of  the  gall-bladder;  or  once  in  2300  autopsies 
according  to  Kelynac.  Its  commonest  seat  is  in  the  common  duct, 
at  or  near  the  papilla.  It  is  equally  frequent  in  males  and  females 
indicating  that  cholelithiasis  is  less  important  as  a  causative  factor, 
than  in  carcinoma  of  the  gall-bladder. 

The  symptoms  of  this  condition  are  those  of  a  gradually  increasing 
closure  of  the  common  duct,  progressive  jaundice  without  pain,  and 
the  gradual  development  of  asthenia,  anemia,  and  loss  of  weight. 
Cholemic  itching  and  a  tendency  to  hemorrhage  are  present  in  the 
later  stages.  In  these  cases,  as  in  all  other  cases  of  common  duct 
obstruction  from  new  growth,  there  will  occur  an  enlargement  of  the 
gall-bladder  from  a  backing  up  of  the  bile.  This  does  not  occur  in  the 
majority  of  instances  where  the  obstruction  is  due  to  an  impacted 
calculus,  a  fact  to  which  Courvoisier  called  attention  many  years  ago. 
Benign  tumors  of  the  duct  give  rise  to  no  symptoms  unless  they 
cause  stenosis.  When  this  occurs  the  symptoms  are  those  of  progres- 
sive jaundice,  but  without  the  rapid  cachectic  wasting  of  cancer. 
Exceptionally  the  jaundice  may  be  intermittent,  due,  as  in  a  case 
reported  by  Courvoisier,  to  a  small  pedunculated  tumor  near  the 
papilla  which  acted  as  a  ball  valve. 

Common  duct  obstruction  from  the  outside  pressure  of  a  carcinoma 
of  the  head  of  the  pancreas,  from  an  extension  to  the  ducts  of  a  pyloric 
cancer,  from  the  enlarged  lymph  nodes  of  cancer  metastasis  or  Hodgkins 
disease,  or  from  a  chronic  interstitial  pancreatitis,  will  all  result  in 
the  occurrence  of  a  progressive  painless  afebrile  jaundice,  simulating 
cancer  of  the  ducts.  In  many  of  these  cases  a  positive  diagnosis  ran 
only  be  made  by  exploratory  operation. 


OPERATIONS  ON  LIVER,  GALL-BLADDER,   AND  DUCTS     585 

The  prognosis  in  duct  cancer  is  bad.  A  few  cases  of  cancer  of  the 
papilla  have  been  operated  upon  with  success,  but  the  author  knows 
of  no  instance  of  cancer  in  other  portions  of  the  duct  being  cured  by 
operation. 

Treatment. — Carcinoma  of  the  gall-bladder,  if  discovered  early, 
should  be  completely  removed  by  cholecystectomy,  including  a 
considerable  area  of  the  underlying  liver,  if  this  is  at  all  involved. 
Benign  tumors  of  the  ducts  occasionally  may  be  removed  surgically. 
Carcinoma  of  the  common  bile  duct,  when  small  and  situated  at  or 
near  the  papilla  can  be  removed  by  a  transduodenal  operation.  In 
rare  instances,  when  a  small  tumor  of  the  common  duct  above  the 
papella  is  discovered  on  exploratory  operation  to  be  in  an  accessible 
position,  it  can  be  removed  by  excision  of  the  diseased  area,  followed 
by  an  end-to-end  anastomosis  or  by  implantation  of  the  proximal 
extremity  of  the  duct  into  the  duodenum.  More  advanced  cases  of 
duct  cancer  and  inoperable  tumors  of  other  organs  producing  per- 
manent occlusion  of  the  common  duct  may  be  treated  palliatively 
by  cholecystenterostomy  or  anastomosing  of  the  gall-bladder  to  the 
duodenum,  jejunum,  or  colon.  The  immediate  mortality  in  these 
palliative  operations  is  high  and  the  measure  of  relief  often  small, 
and  for  that  reason  most  conservative  surgeons  are  inclined  to  advise 
against  operation  in  all  cases  of  advanced  malignant  disease  of  these 
organs. 

OPERATIONS  ON  THE  LIVER,  GALL  BLADDER,  AND  DUCTS. 

Resection  of  the  Liver. — This  operation  is  undertaken  for  the 
removal  of  primary  malignant  growths,  small  echinococcus  cysts, 
or  hopelessly  injured  areas.  It  is  generally  advisable  to  remove  a 
triangular  area,  the  base  of  which  corresponds  with  the  free  edge. 
Two  long-bladed  stomach  or  intestinal  clamps  are  applied  just  beyond 
the  area  to  be  removed.  The  clamps  should  have  moderately  flexible 
blades  covered  with  rubber  tubing  to  prevent  injury  to  the  liver  tissue. 
After  application  of  the  clamps  the  pathologic  area  is  excised  with  a 
scalpel  and  the  visible  bloodvessels  clamped  and  ligated.  Several 
deep  mattress  sutures  are  then  passed,  about  one  inch  from  the  incised 
border,  and,  after  removal  of  the  clamps,  the  cut  edges  are  pressed 
together  and  the  mattress  sutures  tied.  In  passing  the  sutures  only 
a  blunt  needle  should  be  employed,  and  the  suture  material  should  be 
heavy,  plain  catgut.  If  no  bleeding  occurs,  the  peritoneal  cavity 
may  be  closed  without  drainage. 

Cholecystotomy. — Cholecystotomy  consists  in  opening  the  gall- 
bladder for  purposes  of  exploration  or  for  the  removal  of  a  foreign  body. 

The  abdomen  should  be  opened  by  a  longitudinal  incision  near 
the  outer  border  of  the  right  rectus  muscle,  extending  from  the  carti- 
lage of  the  eighth  rib  to  a  point  opposite  the  umbilicus.  The  gall- 
bladder is  drawn  upward  into  the  wound  and  the  peritoneum  protected 


586  DISEASES  OF   THE  ABDOMEN 

by  gauze  pads.  An  incision  is  made  in  the  fundus,  and  the  foreign 
body  removed,  after  which  the  opening  is  closed  with  two  rows  of 
Lembert  sutures,  the  parts  disinfected,  and  the  gall-bladder  returned 
to  the  abdominal  cavity,  which  is  closed  by  layer  suture. 

Cholecystostomy. — In  cholecystostomy  for  drainage  of  the  gall- 
bladder, the  viscus  is  exposed  as  in  cholecystotomy.  Two  circular 
purse-string  sutures  are  introduced  into  the  peritoneal  covering  of  the 
fundus  of  the  gall-bladder,  the  first  making  a  circle  about  one-third 
inch  in  diameter,  the  second  surrounding  the  first  and  about  one-third 
inch  from  it.  An  incision  is  then  made  within  the  inner  circle  and  a 
rubber  drainage  tube  introduced.  As  the  tube  is  being  passed  into 
the  bladder  the  first  suture  is  tightened  and  knotted;  the  tube  is  then 
pushed  further  inward,  carrying  with  it  a  funnel-like  depression  of 
the  fundus,  as  the  second  suture  is  tied.  The  abdominal  wound  is 
then  partly  closed  and  the  gall-bladder  attached  to  the  parietal  peri- 
toneum by  one  or  two  catgut  sutures.  The  advantage  of  this  method  is 
that  after  the  wound  has  healed  there  is  practically  no  leakage  when 
the  tube  is  removed,  and  a  permanent  and  lasting  fistula  is  thereby 
avoided. 

This  method  may  be  carried  out  even  after  large  incisions  in  the 
gall-bladder  for  the  removal  of  stones,  etc.,  by  the  introduction  of 
a  few  more  sutures. 

Cholecystectomy. — In  this  operation  the  gall-bladder  is  exposed  as 
in  the  other  operations,  the  cystic  duct  located,  freed  from  its  peritoneal 
coverings,  and  double  ligated  with  silk  or  heavy  chromicized  catgut. 
The  cystic  artery,  which  lies  to  the  inner  side  of  the  duct,  should 
then  be  exposed  and  tied.  The  gall-bladder  is  next  separated  from 
the  under  surface  of  the  liver  by  blunt  dissection,  after  first  incising 
its  peritoneal  covering  at  its  junction  with  the  liver.  When  the  gall- 
bladder is  thoroughly  separated  from  the  liver  the  cystic  duct  is  divided 
between  the  two  ligatures  and  the  organ  removed.  Hemorrhage 
should  be  arrested  by  ligating  any  bleeding  points  and  by  gauze 
packing  pressed  against  the  raw  surface  of  the  liver.  After  all  bleeding 
has  been  controlled,  any  raw  surfaces  may  be  covered  by  suturing  over 
them  a  portion  of  the  round  ligament  or  omentum.  This  is  an  impor- 
tant part  of  the  operation,  as  it  may  prevent  the  occurrence  of  trou- 
blesome stenosing  adhesions.  The  abdominal  wound  is  then  partly 
closed,  leaving  a  cigarette  drain  which  should  extend  to  Morison's 
pouch. 

Choledochotomy. — In  choledochotomy,  or  opening  one  of  the  bile- 
ducts  for  the  removal  of  a  stone  or  for  drainage,  a  large  abdominal 
incision  should  be  made  through  the  right  rectus  muscle,  extending  as 
high  as  possible.  If  the  abdominal  wall  is  thick,  the  S-shaped  incision 
of  Bevan  will  give  an  excellent  exposure.  It  is  made  by  adding  an 
oblique  inward  cut  to  the  upper,  and  an  oblique  outward  cut  to  the 
lower  end  of  the  regular  straight  rectus  incision.  When  the  gall- 
bladder region  is  freely  exposed  and  the  intestines  well  walled  off  by 


OPERATIONS  ON  LIVER,  GALL-BLADDER,   AND  DUCTS     587 

large  masses  of  handkerchief  gauze,  the  operator  introduces  his  left 
hand  deeply  into  the  wound  and  carries  the  index  finger  into  the  lesser 
peritoneal  sac  through  the  foramen  of  Winslow.  With  the  forefinger 
in  the  foramen  and  the  thumb  above  the  free  edge  of  the  lesser  omen- 
tum, the  hepatic,  cystic,  and  common  ducts  may  easily  be  palpated 
as  far  as  the  pancreas.  If  a  stone  is  detected,  the  duct  is  raised  with 
the  underlying  finger,  and  brought  as  near  the  surface  wound  as 
possible.  The  stone  is  recognized,  and  after  the  duct  is  freely  exposed 
by  removal  of  the  peritoneal  covering  it  is  incised  longitudinally  and 
the  stone  removed.  A  probe  should  then  be  passed  upward  and  down- 
ward to  insure  patency  of  the  remaining  portions  of  the  duct.  Occa- 
sionally it  may  be  impossible  to  determine  by  the  probe  whether  the 
duct  contains  more  stones  or  not.  If  the  duct  is  sufficiently  dilated 
this  question  can  easily  be  settled  by  digital  exploration;  if  not,  careful 
external  palpation  through  the  walls  of  the  duodenum,  and  over  the 
head  of  the  pancreas  may  enable  one  to  detect  the  presence  of  a  stone 
in  the  lower  part  of  the  duct  or  ampulla  of  Vater.  It  must  be  admitted, 
however,  that  in  certain  rare  instances  this  point  cannot  be  absolutely 
determined  by  any  safe  procedure.  Closure  of  the  duct  wound  should 
never  be  complete  where  stone  has  been  found,  for  a  certain  amount 
of  infection  seems  always  to  be  present.  If  the  evidences  of  duct 
infection  are  slight,  closure  may  be  effected  by  a  few  interrupted 
sutures,  leaving  sufficient  space  between  them  to  insure  drainage  if 
any  back  pressure  or  obstruction  to  the  outward  flow  of  bile  into  the 
intestine  occurs.  A  large  cigarette  drain  should  then  be  carried  down 
to  the  line  of  suture.  In  the  great  majority  of  instances  it  is  wiser  to 
introduce  hepaticus  drainage  by  means  of  a  rubber  tube.  It  should 
be  introduced  into  the  hepatic  portion  of  the  duct  and  held  in  place 
by  a  single  catgut  suture.  This  should  be  accompanied  by  a  cigarette 
drain  to  the  region  of  the  duct,  and  if  much  infection  is  present,  a 
second  to  Morison's  pouch.  The  cigarette  drain  can  be  removed  at 
the  end  of  forty-eight  hours,  the  tube  should  be  left  in  place  con- 
siderably longer. 

Transduodenal  Choledochotomy. — Duodenotomy,  for  removal  of  a 
stone  in  the  lower  third  of  the  common  duct,  has  been  recommended 
by  McBurney  as  an  easier  and  safer  method  than  by  exposing  the 
duct  at  this  part.  An  incision  is  made  in  the  second  portion  of  the 
duodenum,  parallel  with  the  long  axis  of  the  bowel,  the  position  of  the 
stone  recognized  by  palpation  and  inspection,  and  its  removal  effected 
by  an  incision  through  the  mucous  membrane  into  the  diverticulum 
of  Vater  or  the  duct.  The  external  duodenal  wound  is  then  closed 
by  two  rows  of  Lembert  sutures,  the  surrounding  parts  carefully 
disinfected,  and  the  abdominal  wound  partly  closed  with  drainage. 

Cholecystenterostomy. — This  operation  occasionally  is  indicated  in 
cases  of  inoperable,  complete,  and  permanent  obstruction  of  the  com- 
mon duct  and  in  certain  cases  of  biliary  fistula.  When  possible,  the 
fundus  of  the  gall-bladder  is  anastomosed  to  the  second  portion  of  the 


."vs  DISEASES  OF   THE  ABDOMEN 

duodenum.  When  this  is  impossible  on  account  of  adhesions,  or  a 
misplaced  or  small  gall-bladder,  union  with  the  stomach,  the  jejunum, 
or  even  with  the  hepatic  flexure  of  the  colon,  may  be  made.  The 
best  method  of  effecting  this  anastomosis  is  by  the  use  of  a  small 
Murphy  button,  the  technic  of  which  has  already  been  described. 
After  the  two  halves  of  the  button  have  been  joined  the  line  of  union 
may  be  protected  and  strengthened  by  wrapping  it  with  a  mass  of 
omentum  and  securing  it  in  place  by  two  or  three  catgut  sutures. 

In  all  operations  upon  the  bile  ducts  it  should  be  remembered 
that  elevation  of  the  upper  lumbar  region  by  means  of  the  adjustable 
kidney  rack  of  the  modern  operating  table  or  by  a  pad  or  cushion, 
placed  beneath  the  lower  dorsal  region,  will  increase  to  a  considerable 
extent  the  exposure  of  the  part-. 

DISEASES  OF  THE  PANCREAS. 

Among  the  congenital  malformations  of  the  pancreas  may  be 
mentioned  the  rare  instances  of  complete  absence  of  the  organ;  acces- 
sory glandular  masses  located  above  or  below  the  pancreas  generally 
near  the  head;  the  annular  pancreas  completely  surrounding  the 
duodenum,  and  the  small  aberrant  nodules  occasionally  found  in  the 
walls  of  the  duodenum.  These  anomalies  are  of  no  surgical  importance, 
but  the  possibilitv  of  their  occurrence  should  be  remembered,  as  they 
are  not  infrequently  mistaken  for  new  growths. 

Pancreatitis. — Infection  may  reach  the  pancreas  by  means  of  a 
penetrating  wound,  as  in  a  gunshot  or  stab  injury  of  the  abdomen; 
by  the  blood  current,  as  in  mumps  and  other  infectious  diseases;  by 
an  ascending  infection  along  the  duct,  often  brought  about  by  the 
regurgitation  of  infected  bile  when  the  duodenal  orifice  of  the  diverticu- 
lum of  Vater  is  closed  by  a  calculus  or  new  growth;  by  the  lymphatics, 
in  gall-bladder  or  duct  infections,  or  from  lesions  of  the  stomach, 
duodenum,  or  vermiform  appendix;  and  by  direct  extension  of  an 
inflammatory  process  from  some  adjacent  organ  or  tissue. 

Various  theories  have  been  suggested  to  account  for  the  sequence 
of  events,  which  takes  place  when  the  pancreas  is  the  seat  of  a  virulent 
infection.  The  first  is  that  infection  in  the  gland  produces  a  chemical 
substance  or  kinase,  which  activates  the  tripsinogen  of  the  pancreatic 
juice  producing  trypsin.  This  in  turn  causes  a  digestion  of  proteid 
material  resulting  in  necrosis  and  hemorrhage.  Another  theory  is 
that  toxic  agents  in  the  blood  produce  hemorrhagins  which  cause  a 
necrosis  of  the  endothelium  of  the  bloodvessels  giving  rise  to  single 
or  multiple  hemorrhages.  Opie  has  demonstrated  that  simple  regurgi- 
tation of  bile  into  the  canal  of  Wirsung  in  animals,  is  capable  of  pro- 
ducing an  acute  pancreatitis.  The  frequent  association  of  pancreatitis 
with  cholelithiasis  and  infection  of  the  biliary  passages,  led  to  the  early 
belief  that  the  majority  of  cases  of  acute  pancreatitis  were  due  to 
regurgitation  of  infected  bile;  but  of  late  the  tendency  has  been  to 


DISEASES  OF  THE  PANCREAS  589 

look  upon  the  extension  of  infection  from  the  biliary  passages  by  the 
lymphatic  route  as  more  common. 

A  study  of  the  lymphatic  arrangement  of  the  pancreas,  gall-bladder 
and  ducts,  duodenum,  and  the  stomach,  will  show  that  there  is  a  very 
free  anastomosis  between  the  lymph  channels  of  all  of  these  structures ; 
and  in  an  acute  infection  in  any  of  these  organs,  with  blocking  of  one 
or  more  of  the  larger  lymph  channels,  a  reversed  current  of  the  lymph 
stream  might  easily  carry  infection  to  the  pancreas.  Whatever 
the  source  of  infection,  the  most  important  factor  in  acute  pancreatitis 
is  the  escape  of  pancreatic  fluid  from  the  duct  or  its  radicals  into  the 
parenchyma  of  the  gland  or  the  surrounding  areolar  tissue  and  fat. 
This  by  its  fat-splitting  ferment  gives  rise  to  a  more  or  less  extensive 
fat  necrosis,  opening  .up  larger  bloodvessels  and  furnishing  a  favorable 
soil  for  the  rapid  extension  of  the  infective  process.  As  a  result  we 
may  have,  early  in  the  disease,  an  extensive  hemorrhage  in  the  gland 
or  escaping  into  the  lesser  peritoneal  cavity,  pancreatic  apoplexy 
or  hemorrhagic  pancreatitis;  single  or  multiple  abscesses,  or  a  diffuse 
suppuration  of  the  entire  gland  and  the  surrounding  fat,  suppurative 
pancreatitis;  or  more  or  less  extensive  areas  of  necrosis,  gangrenous 
pancreatitis.  With  all  of  these  types  of  the  disease,  if  the  process 
continues,  there  will  occur  a  bloody  peritoneal  exudate  which  is  highly 
toxic;  also  multiple  small  areas  of  fat  necrosis  in  the  omentum,  mesen- 
tary,  and  subperitoneal  fatty  tissues.  Occasionally  the  pancreatic 
ferments  are  carried  by  the  blood  and  lymph  currents  to  remote  parts 
of  the  body,  giving  rise  to  fat  necrosis  and  hemorrhages  in  other 
organs  and  tissues. 

In  the  subacute  cases,  the  infection  being  less  virulent,  or  the 
resistance  of  the  individual  greater,  the  resulting  pancreatic  changes  are 
found  chiefly  to  be  hyperemia,  edema,  or  occasionally  a  single  slowly 
forming  abscess.  In  these  cases  the  disease  generally  is  limited  to  the 
head  of  the  gland,  although  solitary  abscesses  of  the  body  and  tail 
occasionally  are  encountered. 

In  chronic  pancreatitis  the  pathological  changes  are  chiefly  repre- 
sented by  an  overgrowth  of  connective  tissue,  which  results  in  a 
hardening  of  the  gland  and  a  pressure  atrophy  of  the  secreting  elements. 
This  in  the  majority  of  instances  occurs  in  the  head  and  body. 

Acute  Pancreatitis. — The  disease  was  first  accurately  described  by 
Fitz  in  1899.  He  called  attention  to  the  fact  that  it  presented  three 
distinct  clinical  types;  the  hemorrhagic,  the  suppurative,  and  the 
gangrenous.  Since  that  time  a  great  deal  of  attention  has  been  given 
to  the  subject  both  by  pathologists  and  clinicians,  and  many  additional 
facts  have  been  collected  regarding  its  etiology  and  clinical  history. 
It  is  now  generally  conceded  that  the  disease  is  essentially  a  surgical 
condition,  as  operation  furnishes  the  only  means  of  successfully  meeting 
the  indications  in  any  of  its  severer  types.  It  has  also  been  observed 
that  the  three  types  described,  by  Fitz  are  often  associated.  It  is 
rare  in  childhood,  and  occurs  most  frequently  in  adults  over  fort}' 


590  DISEASES  OF    TEE  ABDOMEN 

years  of  age.  It  is  slightly  more  common  in  men.  In  a  large  number 
of  instances  its  victims  have  suffered  from  cholelithiasis  or  infection 
of  the  biliary  passages.  Obesity  is  frequently  spoken  of  as  a  predis- 
posing cause,  and  in  some  rare  instances,  trauma  undoubtedly  is  an 
etiologic  factor.  The  disease  in  its  acuter  forms,  is  often  rapidly 
fatal  in  spite  of  prompt  and  rational  treatment. 

Symptoms. — The  symptoms  of  an  acute  pancreatitis  are  characterized 
by  suddenness  and  intensity.  There  is  severe  epigastric  pain  with 
symptoms  of  collapse,  as  pallor,  cold  extremities,  restlessness,  perspira- 
tion, subnormal  temperature,  and  a  rapid  feeble  pulse.  The  abdomen 
at  first  is  retracted,  and  the  muscles  rigid.  Vomiting  occurs  in  the 
majority  of  cases,  with  hiccough,  and  later  dyspnea  from  interference 
with  the  free  action  of  the  diaphragm.  All  of  these  symptoms  may 
progress  rapidly  and  death  may  take  place  in  a  few  hours.  Generally, 
however,  there  is  a  slight  rally  after  the  first  few  hours  of  intense 
suffering,  and  symptoms  of  a  local  or  spreading  peritonitis  supervene. 
The  abdomen  gradually  becomes  distended,  the  muscular  rigidity 
more  extended,  and  signs  of  fluid  in  the  greater  peritoneal  cavity  are 
manifest.  The  temperature  rises,  a  leukocytosis  develops,  the  vomit- 
ing continues,  and  signs  of  an  advancing  paralytic  ileus  occur.  Cases 
seen  in  this  stage  are  not  infrequently  mistaken  for  acute  mechanical 
obstruction  of  the  bowel.  In  less  severe  cases  the  signs  of  peritonitis 
may  be  limited  to  the  epigastric  region.  In  these  instances,  the  local 
process  results  in  abscess,  often  limited  to  the  lesser  peritoneal  sac, 
which  eventually  points  in  the  left  flank.  In  other  cases  pus  may 
burrow  upward  forming  a  subphrenic  collection,  or  it  may  approach 
the  surface  high  up  between  the  stomach  and  liver,  or  between  the 
stomach  and  transverse  colon.  In  these  cases  the  inflammatory 
exudate  easily  can  be  palpated  through  the  abdominal  wall.  In 
many  of  these  abscess  cases  a  more  or  less  extensive  slough  of  the 
pancreas  or  surrounding  fat  is  found  at  operation  or  autopsy.  As 
these  cases,  in  the  early  stage,  often  simulate  rupture  of  a  gastric  ulcer, 
and  later  resemble  acute  intestinal  obstruction,  an  exact  diagnosis 
often  is  impossible  without  an  exploratory  incision.  As  soon  as  the 
abdomen  is  opened,  the  diagnosis  is  confirmed  by  the  presence  of  a 
bloody  serous  exudate,  and  by  numerous  small  white  subperitoneal 
areas  of  fat  necrosis  in  the  omentum,  mesentary  and  upon  the  intestine. 

Treatment. — Except  in  the  milder  cases  which  do  not  present  evi- 
dences of  severe  shock,  and  in  which  improvement  rapidly  follows  rest 
and  expectant  treatment,  all  cases  of  possible  acute  pancreatitis 
should  be  subjected  to  operative  treatment  unless  the  shock  or  general 
sepsis  is  such  as  to  preclude  the  possibility  of  administering  a  general 
anesthetic.  Even  in  these  cases  an  exploratory  incision  under  cocaine 
may  be  undertaken.  The  abdomen  should  be  opened  in  the  median 
line  above  the  umbilicus,  and  the  pancreas  exposed  by  tearing  through 
the  greater  or  lesser  omentum.  Clots  or  gangrenous  masses,  if  present, 
should  be  removed;  hemorrhage  arrested  by  ligature  or  gauze  packing; 


DISEASES  OF  THE  PANCREAS  591 

localized  collections  of  pus  opened,  disinfected  with  hydrogen  peroxide 
and  packed;  larger  areas  of  suppuration  treated  as  intra-abdominal 
abscesses  from  other  causes.  If  possible,  deep-seated  suppuration 
should  be  drained  through  the  back.  Owing  to  the  anatomic  arrange- 
ment of  the  connective-tissue  planes  about  the  pancreas,  suppuration 
in  this  region  tends  to  burrow  toward  the  left  flank,  and  should  there- 
fore be  drained  in  this  region.  In  certain  early  cases  the  pancreas 
may  simply  appear  acutely  inflamed  and  edematous.  In  these, 
incisions  should  be  made  through  the  capsule  and  gauze  drainage 
employed.  At  a  later  period  gangrenous  areas  separate  and  should 
be  removed.  In  all  cases  the  blood  stained  highly  toxic  peritoneal 
exudate  should  be  removed.  The  disease,  unless  treated  surgically 
in  the  earlier  stages,  is.  an  exceedingly  fatal  one.  This,  however,  should 
not  deter  the  surgeon  from  operating  late,  as  brilliant  results  are 
occasionally  achieved  by  thorough  operation  and  energetic  post- 
operative stimulation. 

Prognosis. — Severe  cases  of  acute  pancreatitis,  as  described  above, 
are  almost  always  fatal  without  operation.  Undoubtedly  a  few  of 
the  milder  cases  presenting  acute  symptoms  for  a  few  hours  only, 
and  then  showing  rapid  improvement,  may  recover  spontaneously. 
When  operation  is  undertaken  early  in  the  disease,  and  carried  out 
without  too  much  trauma  and  shock,  the  outlook  is  favorable,  for  so 
grave  a  condition,  as  upwards  of  50  per  cent,  of  the  cases  may  be  saved. 

In  the  milder  abscess  cases,  seen  late,  the  prognosis  is  still  more 
favorable. 

Subacute  Pancreatitis. — In  very  mild  and  non-suppurative  infections 
of  the  head  of  the  pancreas,  we  have  an  entirely  different  clinical 
picture.  Often  there  is  no  pain,  no  fever,  and  no  tenderness;  the  only 
symptom  being  obstruction  of  the  common  duct,  producing  the 
so-called  "  catarrhal  jaundice."  In  other  cases  there  may  be  moderate 
pain  and  tenderness  for  a  few  days,  with  or  without  a  slight  rise  in 
temperature.  There  is  anorexia,  sometimes  nausea  and  vomiting; 
jaundice  may  or  may  not  be  present.  These  symptoms  generally 
subside  with  rest  in  bed  and  attention  to  diet,  but  occasionally  they 
may  recur  when  the  patient  is  again  up  and  about.  In  two  such 
instances  the  writer  was  at  a  loss  to  account  for  the  recurrence  of 
symptoms  after  an  apparent  cure.  In  each  case,  however,  as  a 
result  of  a  careful  physical  examination,  a  definite,  local  point  of 
tenderness  was  found,  in  one  instance  over  the  head  of  the  gland,  in 
the  other  to  the  left  of  the  spine.  Later  these  cases  were  explored, 
and  in  each  instance,  a  small  circumscribed  abscess  was  found  at  the 
point  of  tenderness.  In  the  first  case  there  was  moderate  fever  at 
the  time  of  operation;  in  the  other  there  had  been  no  fever  for  two  or 
more  weeks,  only  pain  and  nausea,  wThen  the  patient  attempted  to 
leave  the  bed.  These  cases  have  been  extensively  studied  by  Deaver, 
who  believes  them  to  be  due  often  to  the  extension  of  a  mild  infection 
from  the  biliary  passages,  stomach,  or  duodenum,  by  means  of  the 


592  DISEASES  OF   THE  ABDOMEN 

lymphatics,  pancreatic  lymphangitis.  As  the  common  bile  duct  is  com- 
pletely surrounded  by  the  head  of  the  pancreas  in  over  60  per  cent, 
of  the  cases,  it  is  easy  to  appreciate  that  an  inflammatory  exudate 
or  even  a  simple  lymphedema  of  the  head  of  the  pancreas,  might 
exert  sufficient  pressure  on  the  duct  to  give  rise  to  a  temporary 
obstruction.  It  is  probable  that  a  mild  degree  of  pancreatitis  is 
present  in  many  cases  of  neighboring  infection,  but  unless  the  infec- 
tion is  of  sufficient  intensity  to  give  rise  to  a  febrile  reaction,  pain  or 
toxemia;  and  unless  the  common  duct  is  occluded  by  the  surrounding 
outside  pressure,  no  symptoms  are  produced.  Deaver  has  expressed 
the  opinion  that  these  mild  symptomless  attacks  of  lymphangitis  of 
the  head  of  the  pancreas,  may  represent  the  early  stage  of  the  chronic 
interstitial  pancreatitis  to  be  described  in  the  next  section.  As  the 
majority  of  these  cases  subside  spontaneously,  the  only  opportunity 
of  verifying  their  presence  is  during  an  operation  for  cholelithiasis, 
or  infection  of  the  gall-bladder  or  ducts.  In  these  instances  one  may 
easily  palpate  the  head  of  the  pancreas  by  the  finger  introduced  into 
the  lesser  sac  through  the  foramen  of  Winslow.  When  subacute 
pancreatitis  of  the  head  of  the  gland  is  present,  the  finger  will  easily 
detect  the  swelling,  increased  density,  and  edema  of  the  gland. 
Enlarged  lymph  nodes  about  the  head  of  the  gland  and  along  the  bile 
ducts,  generally  accompany  this  condition.  Removal  of  the  original 
focus  of  infection  and  drainage  of  the  biliary  passages,  frequently 
hastens  resolution  of  the  pancreatic  lesion. 

Chronic  Pancreatitis. — Chronic  pancreatitis  is  usually  an  interstitial 
inflammation  resulting  in  a  localized  or  general  cirrhosis  of  the  gland, 
due  generally  to  a  long-continued  infection  of  the  canal  of  Wirsung 
and  its  branches,  or  as  Deaver  suggests  to  a  late  stage  of  a  subacute 
lymphagitis.  In  79  cases  reported  by  this  author,  72  presented 
evidences  of  previous  infection  of  the  biliary  passages.  Opie  describes 
two  types,  the  interlobular  and  the  interacinar.  Both  give  rise  to  an 
overgrowth  of  the  connective  tissue  of  the  gland;  but  the  latter,  by  a 
gradual  pressure  atrophy  of  the  islands  of  Langerhans,  causes  diabetes. 
The  interlobular  type,  which  is  the  commonest,  occurs  generally  in 
the  head  of  the  pancreas,  but  may  occur  in  any  other  part  of  the  gland, 
and  is  characterized  by  a  general  hardening  of  the  tissues  without 
enlargement. 

The  condition  has  been  extensively  studied  by  Kehr,  Moynihan,  and 
Mayo-Robson,  who  recognize  in  it  one  of  the  causes  of  chronic 
obstructive  jaundice. 

Symptoms. — The  disease,  as  a  rule,  gives  rise  to  no  pain  or  sign  of 
inflammation.  Usually  there  is  a  history  of  cholelithiasis  or  of  several 
slight  attacks  of  pain  and  tenderness  in  the  epigastric  region.  When 
the  head  of  the  pancreas  is  the  seat  of  the  lesion,  the  two  chief  symptoms 
are  progressive  loss  of  weight  and  jaundice.  The  former  is  always 
present,  the  latter  occurs  in  about  60  per  cent,  of  the  cases,  which  is 
practically  the  percentage  of  cases  in  which  the  common  duct  is  sur- 


TUMORS  OF  THE  PANCREAS  593 

rounded  by  pancreatic  tissue.  As  these  symptoms  are  also  the  chief 
symptoms  of  early  carcinoma  of  the  head  of  the  pancreas,  a  differential 
diagnosis  between  the  two  conditions  is  often  impossible,  even  after 
an  exploratory  operation,  as  in  each  there  is  a  hard,  easily  palpable 
fixed  tumor  behind  the  pylorus  in  the  concavity  of  the  duodenum. 
As  in  other  cases  of  complete  obstruction  of  the  bile  and  pancreatic 
ducts,  the  stools  are  large,  clay  colored,  contain  undigested  meat  fibres, 
and  often  appear  opalescent  from  the  presence  of  fat.  The  urine  is 
concentrated  and  highly  colored  from  the  contained  bile.  Glycosuria 
occasionally  is  observed.  Robson  and  Moyniban  have  recently  called 
attention  to  the  Cammidge  reaction  of  the  urine  as  an  important  aid 
to  diagnosis  in  chronic  pancreatitis.  For  a  description  of  the  technic 
of  this  test  the  reader  is  referred  to  the  original  paper  by  Cammidge.1 

Moynihan  also  states  that  in  his  experience  the  jaundice  of  chronic 
pancreatitis  is  a  lighter  yellow  than  in  carcinoma.  In  the  latter 
condition  the  color  is  deeper  and  presents  a  more  greenish  hue. 

Treatment. — The  curative  effect  of  cholecystenterostomy  and  of 
simple  cholecystostomy  has  been  demonstrated  in  a  number  of  cases 
reported  by  Robson  and  others.  On  account  of  the  difficulties  and 
frequent  errors  in  diagnosis,  all  cases  of  chronic  obstructive  jaundice 
should  be  given  the  benefit  of  one  of  these  procedures,  if  there  is  a 
reasonable  chance  that  the  disease  is  not  malignant. 

TUMORS  OF  THE  PANCREAS. 

Carcinoma. — Primary  carcinoma  of  the  pancreas  is  occasionally 
encountered,  and  when  present  generally  affects  the  head  of  the  gland. 
The  organ  is  more  frequently  involved  secondarily  as  a  result  of 
extension  of  the  disease  from  the  stomach  or  some  other  neighboring 
structure. 

Symptoms. — The  symptoms  of  this  condition  are  a  progressive  loss 
of  weight  and  strength,  accompanied  or  followed  by  jaundice  and 
intense  itching  of  the  skin.  The  jaundice  is  similar  in  its  behavior  to 
other  varieties  of  jaundice  caused  by  a  complete  and  permanent 
obstruction  of  the  common  ducts  in  that  it  is  progressive,  without 
remissions,  and  is  unaccompanied  by  colic.  Digestive  disturbances 
are  always  present  in  the  disease,  and  are  of  the  pancreatic  type; 
steatorrhea,  azotorrhea,  and  an  absence  of  stercobilin  in  the  feces. 

Diagnosis. — The  diagnosis  of  carcinoma  of  the  head  of  the  pancreas  is 
not  always  clear.  In  the  presence  of  a  progressively  increasing  jaundice 
with  loss  of  flesh  and  strength,  one  must  consider  three  conditions — an 
impacted  stone  in  the  common  duct,  chronic  interstitial  pancreatitis, 
and  carcinoma.  Stone  would  be  indicated  by  a  previous  history  of 
biliary  colic,  with  or  without  attacks  of  transitory  jaundice,  by  the 
occurrence  of  pain  at  the  beginning  of  the  present  attack,  and  by  the 

1  Lancet,  March  19,  1904. 
38 


594  DISEASES  OF  THE  ABDOMEN 

absence  of  a  gall-bladder  tumor.  Chronic  pancreatitis,  on  the  other 
hand,  would  not  necessarily  be  associated  with  a  history  of  previous 
calculus  disease  of  the  biliary  passages,  although  that  association 
is  frequently  present.  Pain  never  occurs  as  a  symptom  at  the  begin- 
ning of  a  jaundice  due  to  duct  closure  from  chronic  pancreatitis  or 
cancer.  In  carcinoma  of  the  head  of  the  pancreas  there  is  rarely 
a  history  of  cholelithiasis,  and  the  loss  of  flesh  and  strength  may 
precede  development  of  the  jaundice.  There  is,  moreover,  as  a  rule, 
a  gall-bladder  tumor  due  to  distension  of  the  viscus  with  bile.  Enlarge- 
ment of  the  liver  and  ascites  are  generally  present  late  in  the  disease, 
the  former  due  to  dilatation  of  the  intrahepatic  bile  ducts,  the  latter 
to  pressure  on  the  portal  vein.     The  disease  occurs  late  in  life. 

Treatment. — Treatment  offers  no  hope  for  a  radical  cure  in  carcinoma 
of  the  pancreas,  except  in  those  rare  instances  of  early  primary  disease 
limited  to  a  small  area  in  the  body  or  tail  of  the  organ.  Finney  has 
reported  six  resection  in  such  cases,  with  two  operative  deaths,  and 
no  late  observations.  Cholecystostomy  or  cholecystenterostomy  may 
relieve  for  a  time  the  intense  itching  and  cholemia,  but  any  operation 
in  the  later  stages  of  the  disease  is  associated  with  a  high  mortality. 
In  the  writer's  opinion  it  is  justified  only  when  there  is  a  possibility 
of  the  symptoms  being  due  to  a  chronic  interstitial  pancreatitis. 

Sarcoma. — This  disease  is  rarely  encountered.  Hale  White  reported 
one  case  only  in  6708  autopsies.  It  cannot  be  diagnosticated  before 
operation,  as  in  the  case  of  carcinoma.  Operation  is  indicated  only  in 
small  circumscribed  primary  growths  in  the  body  or  tail.  These 
occasionally  may  be  discovered  as  a  result  of  an  exploratory  operation. 
Four  or  five  such  cases  are  on  record.  The  operative  mortality  being 
about  50  per  cent. 

Cysts. — Cysts  of  the  pancreas  may  be  divided  into  two  classes,  the 
true  cysts  and  pseudo  cysts,  the  former  arising  from  some  pathologic 
condition  in  the  gland,  the  latter,  generally  traumatic  in  origin,  and 
due  to  a  hemorrhage  or  leakage  of  pancreatic  fluid  into  the  lesser 
peritoneal  cavity. 

Of  the  true  cysts,  the  commonest  is  the  cyst-adenoma,  often  similar 
in  structure  to  the  cystadenoma  of  the  ovary  in  that  it  has  a  dense 
fibrous  capsule,  is  generally  multilocular,  and  may  present  on  its 
inner  surface  papillomatous  growths.  It  is  frequently  lined  with 
columnar  epithelium,  but  this  may  be  absent  as  a  result  of  digestion 
by  the  ferments  of  the  contained  fluid. 

The  true  hemorrhagic  cyst  a  slowly  growing  cyst,  generally  traumatic 
in  character,  but  having  its  origin  in  the  glandular  tissue  of  the 
pancreas. 

Retention  cysts  due  to  an  intermittent  obstruction  of  the  duct. 
This  results  in  multiple  small  dilatations  of  the  canal  of  Wirsung, 
and  was  called  by  Virchow  "pancreatic  ranula." 

Hydatid  cysts.  These  are  very  rare,  and  cannot  be  differentiated 
from  the  other  varieties  before  operation. 


TUMORS  OF  THE  PANCREAS  595 

Cystic  degeneration  of  the  pancreas  is  a  congenital  condition,  similar 
to  the  congenital  cystic  kidney,  and  as  a  rule  gives  rise  to  no  symptoms. 

The  false  cysts  as  a  rule  grow  more  rapidly  than  the  true  cysts. 
Both  true  and  false  cysts  contain  fluid  which  on  chemical  examination 
is  found  to  be  alkaline,  albuminous,  and  may  show  one  or  all  of  the 
pancreatic  ferments,  although  their  absence  may  be  noted  in  rare 
instances  in  either  variety.  The  fluid  of  a  pancreatic  cyst  may  be 
clear  and  watery,  or  thick  syrup-like  in  consistency,  and  almost  any 
color.  Generally  it  is  reddish  or  brown  from  the  admixture  of  blood. 
The  presence  of  blood  in  a  cyst  does  not  necessarily  indicate  its  trau- 
matic origin,  for  the  pancreatic  ferments  often  cause  an  erosion  of  a 
vessel  in  the  cyst  wall,  resulting  in  minute  or  more  extensive 
hemorrhage. 

Treatment. — Removal  of  these  cysts  is  generally  out  of  the  question 
on  account  of  their  anatomic  relations.  They  should  therefore  be 
opened,  the  contents  evacuated,  and  permanent  drainage  established 
by  stitching  the  cyst  wall  to  the  abdominal  incision.  Numerous 
cases  have  been  cured  by  this  method,  although  the  secretion  may 
continue  for  many  months.  A  disagreeable  feature  of  the  treatment 
is  the  occurrence  of  an  obstinate  dermatitis  around  the  fistulous 
opening,  due  to  the  corrosive  action  of  the  pancreatic  fluid.  In  a 
certain  proportion  of  the  cyst-adenomata  complete  extirpation  is 
possible,  and  this  is,  of  course,  the  ideal  method  of  treatment. 

Pancreatic  Calculus. — A  rare  condition.  Lazarus,  in  1904,  collected 
records  of  57  cases. 

The  calculi  are  generally  composed  of  calcium  carbonate  and 
phosphate.  They  are  found  in  the  canal  of  Wirsung  and  its  larger 
branches,  often  they  are  multiple,  and  frequently  facetted.  They 
are  easily  shown  by  the  .r-rays.  They  are  generally  associated  with 
a  certain  degree  of  chronic  interstitial  pancreatitis.  Glycosuria 
is  present  in  about  half  of  the  cases. 

Symptoms. — There  may  be  no  symptoms.  Generally  there  is  dull 
pain  or  colic  in  epigastric  region  to  left  of  midline,  or  rarely  over  the 
gall-bladder.  Vomiting  occurs  if  the  pain  is  severe.  Chills  and 
fever  may  be  present  if  infection  is  added.  Jaundice  occurs  if  stone 
is  arrested  in  the  ampulla  of  Vater.  In  the  intervals  between  attacks, 
digestive  disturbances  of  the  pancreatic  type  are  often  present.  The 
Cammidge  reaction  is  frequently  present. 

Treatment. — If  the  stone  is  located  at  the  papilla  it  may  be  removed 
by  a  transduodenal  operation.  If  in  the  body  of  the  gland,  the  pan- 
creas can  be  exposed  by  dividing  the  gastrocolic  omentum,  the 
stones  located  by  palpation,  the  duct  incised,  the  calculi  removed 
by  a  curet  or  scope,  the  duct  wound  tightly  closed  with  catgut  sutures, 
and  the  overlying  gland  tissue  loosely  united  with  interrupted  sutures. 
Generous  gauze  drainage  should  be  inserted  to  provide  for  leakage. 


59G  DISEASES  OF   THE  ABDOMEN 


SURGICAL  DISEASES  OF  THE  SPLEEN. 

Congenital  Anomalies. — Congenital  absence  of  the  spleen  has  been 
reported  in  a  few  instances.  Small  accessory  spleens  are  not  infre- 
quently encountered  near  the  parent  organ.  Occasionally  they  are 
attached  to  the  spleen  by  connective-tissue  bands,  in  other  cases, 
they  are  to  be  found  in  the  gastrosplenic  omentum  or  other  adjacent 
peritoneal  folds.     They  are  of  no  surgical  importance. 

Ectopic  Spleen. — The  spleen  may  be  displaced  and  occupy  almost 
any  position  in  the  abdomen.     The  causes  of  this  condition  are  obscure. 

Symptoms. — There  may  be  no  symptoms;  or  the  wandering  spleen 
may  cause  displacement  of  the  stomach  and  occasion  pain  and  vomit- 
ing; it  may  give  rise  to  intestinal  obstruction  by  pressure  on  the 
bowel,  or  by  the  formation  of  adhesions  may  give  rise  to  a  kinking  of 
the  gut  and  stenosis.  In  a  case  observed  by  the  writer  the  spleen 
was  situated  in  the  pelvic  cavity,  and  was  firmly  adherent  to  the 
sacrum,  rectum,  and  bladder,  producing  symptoms  referable  entirely 
to  the  bladder.  In  this  case  there  was  also  axial  rotation,  the  internal 
surface  pointing  toward  the  left  and  the  anterior  border  being  down- 
ward. Rotation  of  the  spleen  with  twisting  of  the  pedicle,  causing 
strangulation  of  the  vessels,  may  give  rise  to  acute  pain,  vomiting, 
tenderness,  peritoneal  irritation,  and  result  in  gangrene  of  the  organ. 

Diagnosis. — The  diagnosis  occasionally  is  made  by  the  shape  of  the 
tumor,  by  the  recognition  of  its  notched  anterior  border,  and  by  the 
fact  that  frequently  it  can  be  reduced  to  its  normal  position. 

Treatment. — Splenopexy,  or  suturing  the  organ  to  the  diaphragm 
or  posterior  abdominal  wall,  has  been  recommended.  Hose  and 
Carless  recommended  making  a  bed  for  the  wandering  organ  in  the 
retroperitoneal  space  near  its  normal  habitat,  withdrawing  it  through 
an  incision  in  the  parietal  peritoneum,  and  securing  it  by  sutures. 
Splenectomy  is,  however,  the  operation  of  choice.  Of  sixteen  cases 
of  splenectomy  for  this  condition  cited  by  Osier,  fifteen  recovered. 

Abscess  of  the  Spleen. — Abscess  of  the  spleen  is  exceedingly  rare, 
and  generally  is  metastatic  in  origin.  It  is  often  associated  with 
some  acute  infectious  disorder,  as  typhoid  fever,  smallpox,  acute 
rheumatism,  or  gonorrhea.  The  association  of  malaria  with  abscess 
of  the  spleen  has  been  mentioned  by  a  number  of  observers.  Trauma 
has  been  recorded  in  a  few  instances,  especially  when  the  spleen 
subsequently  became  adherent  to  a  loop  of  damaged  intestine.  In  a 
fair  number  of  cases  the  disease  seems  to  result  from  an  infection  of  a 
pre-existing  hematoma. 

Symptoms. — The  symptoms  of  splenic  abscess  arc  pain  and  tender- 
ness in  the  left  hypochondric  region,  muscular  rigidity,  fever,  chills, 
and  leukocytosis.  As  adhesions  frequently  form  between  the  spleen 
and  the  parietal  peritoneum  of  the  diaphragm  and  abdominal  wall, 
symptoms  of  pleurisy  or  infection  of  the  abdominal  parietes  develop. 


SURGICAL  DISEASES  OF  THE  SPLEEN  597 

Treatment.— The  treatment  should  be  incision  and  evacuation  of 
the  pus.  If  pointing  occurs  on  the  surface  of  the  body  the  incision 
should  be  over  the  inflamed  area.  If  no  such  sign  exists,  laparotomy 
is  indicated  with  drainage,  as  in  other  intra-abdominal  abscesses. 

Tuberculosis  of  the  Spleen. — A  number  of  cases  of  splenic  tubercu- 
losis have  been  recorded,  in  some  of  which  the  disease  was  apparently 
primary.  The  spleen  in  this  condition  is  generally  enlarged,  and  more 
or  less  discomfort  and  pain  are  present. 

Bland-Sutton  and  others  have  successfully  removed  the  spleen  for 
this  disease,  with  complete  restoration  to  health. 

Splenomegaly. — The  spleen  may  be  enlarged  in  acute  infectious 
diseases  as  typhoid  fever  or  malaria;  in  tuberculosis,  syphilis,  and 
rickets;  in  cirrhosis  of  the  liver,  and  other  forms  of  portal  obstruction; 
in  leukemia,  Hodgkin's  disease;  hemolytic  icterus,  pernicious  anemia; 
and  in  that  obscure  group  of  pathologic  conditions  classified  as  idio- 
pathic splenomegaly,  Banti's  disease,  or  splenic  anemia. 

While  the  splenic  enlargements  of  acute  and  chronic  infectious 
diseases,  of  cirrhosis  of  the  liver  and  of  leukemia  and  Hodgkin's 
disease,  as  a  rule  are  of  interest  only  to  the  practitioner  of  internal 
medicine,  those  cases  of  splenomegaly  associated  with  certain  pro- 
gressive anemias  due  to  hemolysis,  writh  hemorrhages  and  hemolytic 
icterus,  are  now  regarded  as  presenting  definite  surgical  indications. 
The  first  of  these  conditions  to  be  treated  surgically  was  Banti's 
disease,  which  may  be  described  as  an  exceedingly  chronic  disorder 
presenting  three  distinct  clinical  stages.  First  the  stage  of  gradual 
splenic  hypertrophy  without  other  symptoms  (idiopathic  spleno- 
megaly). This  stage  may  last  from  two  to  seven  years,  and  during 
this  period  the  spleen  may  enlarge  to  such  an  extent  as  to  reach  the 
median  line  and  pelvic  brim.  I  Hiring  the  second  stage  there  occurs  a 
progressive  anemia  of  the  chlorotic  type,  evidenced  by  a  lowered  red 
cell  count,  lowered  percentage  of  hemoglobin,  low  color  index,  leuko- 
penia writh  a  relative  lymphocytosis;  also  gastric  and  intestinal  hemor- 
rhages, evidenced  by  hematemesis  and  melena.  These  hemorrhages 
occur  at  irregular  intervals,  and  may  result  in  extreme  exsanguination. 
During  this  stage  also,  there  is  noted  a  definite  enlargement  of  the 
liver.  The  third  stage  is  that  of  progressive  hepatic  cirrhosis,  the 
enlarged  liver  gradually  shrinking  to  a  small  area,  and  presenting 
all  the  characteristic  fibrous  changes  of  an  alcoholic  cirrhosis.  Ascites, 
increased  gastro-intestinal  hemorrhages,  jaundice,  and  pigmentation 
are  the  characteristic  symptoms  of  this  stage,  and  death  from  loss  of 
blood  or  progressive  asthenia  is  the  inevitable  result  in  untreated 
cases. 

Pathology. — The  pathology  of  the  condition  is  by  no  means  definitely 
determined.  The  changes  in  the  spleen  in  the  early  stage  are,  hyper- 
plasia of  all  the  connective-tissue  elements  of  the  organ,  with  pressure 
atrophy  of  the  Malpighian  corpuscles,  chronic  passive  hyperemia,  and 
endothelial  proliferation  of  the  sinuses.     In  the  Gaucher  type,  this 


598  DISEASES  OF   THE  ABDOMEN 

endothelial  proliferation  may  be  so  great  as  to  cause  huge  masses 
throughout  the  organ,  suggesting  a  neoplasm.  In  addition  to  these 
changes  in  the  spleen  there  is  always  a  chronic  phlebitis  of  the  splenic 
vein,  often  with  great  thickening  and  calcification  of  the  walls;  and  a 
varicose  dilatation  of  its  tributaries  especially  the  vasa  brevia  from  the 
stomach.  The  venous  changes  have  been  regarded  by  some  to  be  the 
primary  lesion,  the  splenic  changes  resulting  from  the  chronic  passive 
hyperemia. 

Symptoms. — The  clinical  course  of  the  Gaucher  type  differs  some- 
what from  the  type  described  by  Banti.  It  occurs  more  often  in  child- 
hood and  appears  frequently  in  several  members  of  a  family.  The 
splenic  enlargement  generally  is  discovered  by  accident  as  there  are 
no  symptoms  until  very  late  in  the  disease,  when  anemia  develops 
with  hemorrhages  from  the  nose  and  gums,  pigmentation  of  the  skin 
of  the  face,  neck  and  hands,  and  lastly  enlargement  of  the  liver. 

Treatment. — In  the  treatment  of  this  condition,  early  splenectomy 
is  to  be  recommended,  as  by  this  means  alone  can  the  progress  of  the 
disease  be  arrested. 

Hemolytic  Icterus. — There  are  two  types  of  this  disease,  the  con- 
genital and  acquired.  In  the  congenital  type  there  may  be  only  a 
slight  jaundice  from  birth,  without  anemia  or  splenic  enlargement; 
or  the  jaundice  may  be  more  marked  with  moderate  splenic  hyper- 
trophy and  anemia.  The  urine  contains  no  bile,  but  urobilin  is  present. 
The  stools  are  normal  in  color.  There  is  as  a  rule  a  certain  amount  of 
variation  in  the  jaundice.  These  cases  run  a  chronic  course,  and  often 
the  health  is  not  impaired.  In  the  acquired  type  the  condition  is 
more  acute,  while  the  symptoms  and  signs  are  the  same  in  character; 
the  anemia  is  more  pronounced,  the  splenic  enlargement  more  marked, 
and  enlargement  of  the  liver  may  be  noted.  In  a  few  instances  in 
which  the  spleen  has  been  removed  for  this  condition  the  results  have 
been  brilliant.  The  jaundice  has  disappeared  or  been  markedly 
improved,  the  urobilin  has  disappeared  from  the  urine  showing  a 
greatly  diminished  destruction  of  red  cells,  and  the  anemia  and  general 
health  have  been  improved. 

Pernicious  Anemia. — As  many  cases  of  pernicious  anemia  seem 
closely  related  to  hemolytic  icterus,  Antonelli  and  Decatello  removed 
the  spleen  in  two  borderline  cases  with  excellent  results.  Later 
Eppinger  reported  two  cases  of  hemolytic  icterus  and  two  cases 
of  pernicious  anemia  successfully  treated  by  splenectomy.  In 
neither  of  the  latter  cases  was  the  spleen  enlarged.  Klemperer  and 
Hirschfeld  reported  two  additional  cases  of  pernicious  anemia  treated 
in  the  same  manner  with  marked  improvement.  Splenectomy 
apparently  acts  in  two  ways  in  these  cases,  first  by  removing  the  chief 
seat  of  the  destruction  of  the  red  cells,  and  second  by  stimulating 
the  bone  marrow.  Polycythemia  has  been  noted  in  a  number  of 
cases  where  the  spleen  has  been  removed  for  trauma  or  Banti 's  disease. 
In  one  case  of  the  latter  disease  Klemperer  and  Hirschfeld  report  an 


TUMORS  OF  THE  SPLEEN  599 

increase  of  red  cells  within  a  year  to  over  7,000, 01)0  and  of  hemoglobin 
to  120  per  cent. 

In  pernicious  anemia,  so  treated,  while  the  blood  picture  shows 
much  improvement  by  the  marked  increase  in  erythrocytes  and  normo- 
blasts, it  does  not  necessarily  lose  the  characteristics  typical  of  the 
disease. 

Hypertrophic  cirrhosis  has  recently  been  treated  successfully  by 
splenectomy,  notably  a  case  reported  by  Eppinger  operated  upon  by 
Brauer. 

TUMORS  OF  THE  SPLEEN. 

Primary  sarcoma,  fibroma,  and  cavernous  angioma  have  been 
observed  in  the  spleen.  Secondary  carcinoma  and  sarcoma  are  more 
common.  The  benign  solid  tumors  of  the  spleen  are  exceedingly 
rare,  and  practically  never  give  rise  to  symptoms  calling  for  surgical 
intervention . 

Sarcoma,  according  to  Moynihan,  may  arise  from  the  capsule  or 
trabecular  when  it  is  of  the  fibrous  or  spindle-cell  type;  from  the 
lymphoid  tissue,  lymphosarcoma;  or  from  the  endothelium,  endothe- 
lioma. In  the  first  form  the  growth  is  slow,  in  the  others  rapid. 
About  one  dozen  such  cases  have  been  treated  by  splenectomy  with 
two  or  three  permanent  recoveries. 

Cysts  of  the  Spleen. — Those  are  divided  into  two  classes,  the  para- 
sitic and  non-parasitic  cysts.  Echinococcus  cysts  of  the  spleen  are 
the  ones  most  frequently  observed.  The  cysts  are  always  unilocular, 
and  according  to  Moynihan  may  arise  from  any  part  of  the  organ, 
but  are  generally  located  in  the  upper  pole.  The  non-parasitic  cysts, 
according  to  Powers,  are  generally  due  to  trauma  giving  rise  to  paren- 
chymatous or  subcapsular  hematoma.  These  cysts  may  contain 
blood,  or  the  fluid  may  be  serous  in  character.  They  may  reach 
a  large  size  and  occasion  symptoms  of  more  or  less  importance.  Gen- 
erally there  is  a  sense  of  weight  or  dragging  in  the  left  hypochondriac 
region.  Occasionally  there  is  acute  pain  or  vomiting  from  pressure 
on  the  stomach  or  intestines.  The  signs  are  those  of  a  globular 
elastic  tumor  in  the  upper  left  quadrant  of  the  abdomen.  The  most 
approved  and  successful  treatment  is  by  splenectomy,  although  cures 
by  drainage  and  marsupialization  have  been  reported.  Splenectomy 
in  the  non-parasitic  cysts  may  be  rendered  difficult  by  the  presence  of 
adhesions. 


CHAPTER  XXII. 

DISEASES  AND  INJURIES  OF  THE  KIDNEYS  AND 
URETERS. 

CONGENITAL  ABNORMALITIES  OF  THE  KIDNEY. 

Congenital  abnormalities  of  the  kidney  which  are  of  surgical 
importance  are,  variations  in  position,  number,  and  form. 

The  position  of  the  kidney  may  be  anywhere  from  its  normal  habitat 
in  the  upper  loin  to  the  floor  of  the  pelvis.  Kidneys  occupying  a 
position  in  the  iliac  fossa  or  pelvis  are  extremely  rare,  may  be 
misformed,  and  are  not  infrequently  mistaken  for  pelvic  growths. 

While  the  presence  of  small  supernumerary  kidneys  are  of  little 
or  no  surgical  importance,  the  occurrence  of  a  single  kidney  only, 
in  an  individual  who  is  the  victim  of  a  surgical  disease  of  that  organ 
is  of  the  greatest  moment. 

The  occurrence  of  a  single  large  kidney  in  its  normal  position, 
with  absence  or  complete  atrophy  of  its  fellow,  may  be  expected 
once  in  every  2500  individuals,  the  actual  number  reported  by  Morris 
in  15,904  autopsies  being  6. 

The  occurrence  of  a  single  renal  mass  formed  by  a  fusion  of  both 
kidneys  is  more  common,  occuring  about  once  in  1000  subjects.  When 
this  is  present,  the  mass  usually  occupies  a  position  in  front  of  the 
spine  near  the  bifurcation  of  the  aorta,  and  is  of  horse-shoe  shape. 
Very  rarely  the  fused  mass  may  be  found  in  the  loin  on  the  right  or 
left  side  of  the  vertebral  column.  The  fused  kidneys  may  be  united 
by  a  bridge  of  kidney  parenchyma,  or  only  by  a  thin  fibrous  band. 
Usually  they  have  two  sets  of  vessels  and  two  ureters. 

The  presence  of  a  double  renal  pelvis  and  ureter  in  a  kidney  otherwise 
normal  is  of  comparatively  frequent  occurrence,  and  may  be  of  surgical 
importance,  especially  in  interpreting  the  results  of  cystoscopic  exami- 
nation. The  writer  found  this  condition  3  times  in  an  examination 
of  150  subjects  in  the  dissecting-room  of  the  College  of  Physicians 
and  Surgeons  of  New  York.  Fig.  288  represents  such  a  condition 
where  the  upper  pelvis  and  ureter  were  the  seat  of  a  tuberculous  process, 
while  the  lower  remained  free. 

Variations  in  the  blood  supply  of  the  kidney  are  frequent.  The 
author  found  in  an  examination  of  150  subjects  a  double  renal  artery 
70  times;  three  arteries,  12  times;  four,  twice;  and  five,  once.  Of 
the  latter,  three  branches  came  from  the  aorta,  one  from  the  common 
iliac,  and  one  from  the  ovarian.     Important  arterial  branches  to  the 


CONGENITAL  ABNORMALITIES  OF  THE  KIDNEY        60] 

upper  and  lower  pole  of  the  kidney  and  to  the  anterior  surface  of  the 
organ  were  found  28  times  (Fig.  289).  These  vascular  bands  passing 
to  the  lower  pole  of  a  kidney  not  infrequently  give  rise  to  intermittent 


Fig.  288. — Double  renal  pelvis  and  ureter.     Tuberculosis  of  upper  pelvis  and  ureter. 


602  DISEASES  OF   THE  KIDNEYS  AND   URETERS 

hydronephrosis  by  pressure  on  the  ureter,  when  the  organ  is  fixed, 
or  by  kinking  of  the  ureter,  when  the  kidney  becomes  movable. 


Fig.  289. — Anomalies  of  renal  artery. 


INJURIES  OF  THE  KIDNEY. 


Although  one  of  the  best  protected  organs  of  the  body,  the  kidney 
is  not  infrequently  injured  by  falls,  blows,  crushes,  severe  muscular 
strain,  gunshot  and  stab  wounds.  These  injuries  are  naturally  divided 
into  two  classes,  those  which  occur  without  an  external  parietal  wound 
leading  to  the  injured  organ,  and  those  accompanied  by  such  a  wound. 
The  former  are  spoken  of  as  svbparietal  injuries,  the  latter  as  open 
wounds. 

Like  simple  fractures,  the  subparietal  injuries  generally  escape 
infection  from  without;  and  although  the  injuries  are  often  serious 
and  require  grave  surgical  procedures  for  their  relief,  a  complicating 
infection  generally  can  be  avoided;  while  in  the  open  injuries,  infection 
has  generally  taken  place  before  the  patient  is  seen  by  the  surgeon. 
The  possibility  of  injury  to  the  kidney  by  severe  muscular  effort 
must  be  admitted,  for  cases  have  been  recorded  in  which  lumbar  pain, 
collapse,  and  hematuria  have  followed  a  sudden  violent  muscular 
strain,  but  by  far  the  largest  number  of  such  injuries  are  caused  by 
crushes,  falls,  or  blows  in  the  lumbar  region. 

Subparietal  Injuries. — Subparietal  injuries  of  the  kidney  may  be 
conveniently  divided  into  three  grades:  (1)  simple  contusion  with  or 
without  injury  to  the  capsule  and  subcapsular  hemorrhage;  (2)  incom- 


INJURIES  OF   THE  KIDNEY  003 

plete  rupture,  in  which  the  parenchyma  is  fractured,  but  without 
opening  the  pelvis;  and  (3)  complete  rupture,  in  which  the  entire 
organ  is  torn  across,  freely  opening  the  pelvic  cavity. 

In  simple  contusion  there  is  often  a  laceration  of  the  fatty  capsule 
with  a  very  moderate  amount  of  hemorrhage.  One  or  more  fissures 
of  the  fibrous  capsule  may  occur  with  ecchymoses,  and  occasionally 
a  large  area  of  the  fibrous  capsule  is  raised  by  the  presence  of  extrav- 
asated  blood.  In  ruptures  of  the  parenchyma  the  line  of  fissure 
generally  corresponds  with  the  direction  of  the  bloodvessels.  When 
limited  to  the  cortex,  the  hemorrhage  is  moderate;  but  when  complete 
rupture  occurs  and  the  large  vessels  are  torn,  the  hemorrhage  is  pro- 
fuse, often  forming  an  enormous  retroperitoneal  hematoma  or  intra- 
peritoneal extravasation  if  that  membrane  is  lacerated  by  the  original 
injury  or  ruptured  by  the  pressure  of  the  extra vasated  blood.  When 
the  pelvis  or  ureter  is  injured,  urinary  extravasation  necessarily  occurs, 
giving  rise  to  a  constantly  increasing  tumor  in  the  flank,  and  not 
infrequently  furnishing  a  source  of  infection.  It  occasionally  happens 
that,  as  a  result  of  a  trauma,  the  kidney  escapes  damage,  the  only 
injury  being  rupture  of  one  of  the  vessels  of  the  pedicle,  generally  a  vein. 

Symptoms. — These  vary  with  the  extent  of  the  injury.  In  simple 
contusion  there  may  be  only  the  history  of  a  blow  or  fall,  a  slight 
soreness  about  the  loin,  and  the  passage  of  urine  tinged  writh  blood. 
In  severe  cases  the  pain  is  more  marked,  and  may  be  of  paroxysmal 
character,  radiating  downward  along  the  course  of  the  ureter  and  into 
the  testicle,  this  presumably  due  to  the  passage  of  blood  clots  along 
the  ureter.  If  there  has  been  a  considerable  extravasation  of  blood 
in  the  perirenal  tissues,  a  tumor  may  be  felt,  and  possibly  fluctuation. 
The  hematoma  may  be  marked  and  persist  for  many  days;  occasionally 
the  blood  collects  in  the  bladder  so  rapidly  that  an  enormous  clot  is 
formed  distending  that  organ  and  giving  rise  to  retention.  There  is 
moderate  shock,  evidenced  by  pallor,  a  rapid,  feeble  pulse,  cold  extrem- 
ities, and  occasionally  nausea  and  vomiting.  Later,  suppuration  may 
occur,  forming  a  more  or  less  extensive  retroperitoneal  abscess,  the 
symptoms  of  which  are  general  malaise,  local  throbbing  pain,  fever, 
chills,  wasting,  and  the  presence  of  a  tender  mass  in  the  flank.  In  the 
severest  forms  shock  is  the  prominent  symptom.  This  is  due  to 
hemorrhage  either  extraperitoneal  or  intraperitoneal,  and  not  infre- 
quently to  injury  to  other  organs  caused  by  the  same  trauma.  The 
presence  of  a  tumor  in  the  loin  or  marked  local  tenderness  with  hema- 
turia furnishes  the  surgeon  with  sufficient  data  on  which  to  base  a 
diagnosis,  although  the  patient  may  be  unable  to  describe  the  accident 
or  his  sensations.  These  cases  are  often  rapidly  fatal  from  shock  due 
to  hemorrhage  or  the  effects  of  concurrent  injuries. 

A  group  of  persistent  symptoms  has  been  described  as  occasionally 
following  the  mildest  contusions,  which  merit  special  attention. 
These  are  paroxysmal  pain,  fever,  hematuria,  and  frequent  micturition, 
occurring  weeks  or  months  after  such  an  injury,  and  strongly  suggesting 


004  DISEASES  OF   THE   KIDNEYS  AND   URETERS 

the  presence  of  renal  calculus.  Exploration  reveals  in  these  cases 
extensive  subcapsular  hematomata,  but  nothing  else.     The  symptoms 

are  completely  relieved  by  removal  of  the  lesion.  In  such  a  case 
observed  by  the  writer  at  the  Roosevelt  Hospital  an  .r-ray  photograph 
showed  a  faint  shadow  in  the  region  of  the  blood  clot,  which  still 
further  obscured  the  diagnosis. 

Prognosis. — As  in  the  case  of  all  visceral  injuries,  the  prognosis 
should  he  guarded.  The  mild  cases  recover  almost  without  exception, 
and  even  the  cases  with  extensive  hematomata  result  favorably  if 
infection  is  avoided. 

Where  urinary  infiltration  complicates  the  injury,  the  prognosis 
is  more  grave,  and  where  these  and  the  severer  forms  of  injury  cannot 
receive  prompt  surgical  assistance  the  outlook  is  bad. 

It  is  a  well-recognized  fact  that  injury  to  an  organ,  particularly 
the  kidney,  will  so  affect  its  nutrition  as  to  diminish  its  normal  resist- 
ance to  septic  infection.  The  frequent  occurrence  of  septic  infarcts 
or  an  ascending  infection  in  a  previously  injured  kidney  has  been 
noted  by  all  clinical  observers. 

Treatment. — Except  in  the  mildest  contusions,  all  cases  of  injury 
to  the  kidney  immediately  should  be  explored,  for  the  reason  that 
the  early  symptoms  often  give  no  adequate  idea  of  the  extent  of  the 
injury.  Unless  there  are  evidences  of  intraperitoneal  injury  the 
exploration  should  be  by  the  lumbar  route.  This  exposure  of  the 
kidney  and  retroperitoneal  space  will  enable  the  surgeon  to  estimate 
correctly  the  extent  of  the  injury,  arrest  the  hemorrhage,  remove  the 
clot  and  extravasated  urine,  and  provide  adequate  drainage.  The 
treatment  of  the  injured  organ  must  be  determined  by  the  extent 
of  the  trauma.  If  the  kidney  is  simply  torn  apart,  often  it  may  be 
saved  by  careful  approximation  of  the  divided  portion  even  if  the 
cavity  of  the  pelvis  is  invaded,  for  the  great  vascularity  of  the  organ 
favors  rapid  repair. 

The  placing  of  a  few  catgut  sutures  through  the  capsule,  or  even 
through  the  kidney  itself,  will  be  sufficient  to  insure  continued  approx- 
imation until  repair  has  taken  place.  Whenever  the  pelvis  is  opened 
and  hemorrhage  is  free,  it  is  wise  before  closing  the  rent  to  insure 
patency  of  the  ureter  by  the  passage  of  an  ureteral  catheter  to  the 
bladder. 

Whenever  urinary  extravasation  has  occurred,  the  wound  should 
be  left  partly  open  and  generously  drained  with  gauze  or  rubber  tubes. 

In  the  severe  forms,  in  which  the  kidney  is  not  only  torn,  but  also 
crushed  and  large  areas  of  the  parenchyma  destroyed,  and  in  cases 
in  which  the  blood  supply  has  been  seriously  compromised  or  in  which 
the  pelvis  or  ureter  has  been  injured  beyond  repair,  nephrectomy 
should  be  practised.  Nephrectomy  is  occasionally  advisable  also  in 
cases  of  severe  shock  accompanied  by  grave  hemorrhage,  in  which 
prolonged  attempts  at  repair  would  not  be  tolerated. 

Prompt  healing  may  be  expected  in  those  cases  which   recover 


INJURIES  OF   THE  KIDNEY  G05 

from  the  immediate  shock  of  the  injury  and  operation,  if  infection 
can  be  prevented.  Where  infection  occurs,  however,  the  suppurating 
area  is  apt  to  be  large  and  the  resulting  toxemia  great,  seriously 
interfering  with  repair,  and  often  exhausting  the  patient's  vital  forces 
before  recovery  can  take  place.  In  these  cases  secondary  nephrectomy 
is  often  necessary  to  save  life,  and  should  not  be  too  long  delayed. 

Open  Wounds. — Open  wounds  of  the  kidney  in  the  great  majority 
of  cases  are  gunshot  or  stab  injuries,  although  crushes  may  result  in 
compound  fractures  of  the  lower  ribs,  and  severe  railway  accidents, 
machinery  injuries,  and  the  flying  debris  from  explosions  may  cause 
them.  Abbe  has  reported  a  case  in  which  the  pole  of  a  truck  pene- 
trated the  thorax,  lacerating  the  lung,  liver,  and  kidney. 

In  these  instances,  in  addition  to  the  other  dangers  we  have  the 
added  risk  of  infection,  as  bits  of  clothing  and  other  infected  matters 
are  practically  always  present  in  the  wound,  a  circumstance  which 
should  lead  the  surgeon  to  an  immediate  exploration  in  every  instance 
in  which  the  patient's  condition  justifies  the  administration  of  an 
anesthetic.  After  the  wounded  area  is  freely  exposed  and  disinfected 
the  same  principles  should  be  carried  out  in  the  treatment  of  the 
injured  organ  as  in  cases  of  subparietal  injury. 

In  gunshot  and  stab  injuries  when  the  direction  of  the  wound 
leads  one  to  infer  that  the  peritoneal  cavity  may  be  injured,  it  is 
advisable  to  perform  an  immediate  exploratory  laparotomy,  even 
in  the  absence  of  symptoms  of  intra-abdominal  lesion. 

Aneurism  of  the  Renal  Artery. — True  spontaneous  aneurism  of  the 
renal  artery  is  exceedingly  rare. 

True  or  false  aneurism  arising  as  a  result  of  trauma  is  of  more 
frequent  occurrence,  but  is  seldom  recognized.  True  traumatic 
aneurism,  or  one  in  which  the  walls  are  formed  by  one  or  more  coats 
of  the  artery,  rarely  reaches  a  large  size  without  rupture. 

When  such  an  aneurism  ruptures,  or  when  as  a  result  of  injury 
a  healthy  arterial  trunk  is  ruptured,  a  false  aneurism  may  result, 
the  walls  which  may  be  formed  by  the  fibrous  capsule  of  the  kidney, 
the  distended  pelvic  cavity,  the  parenchyma  of  the  organ,  or  the  sur- 
rounding areolar  tissue.  This  aneurism  may  enlarge  slowly  or 
rapidly,  and  eventually  may  form  a  tumor  large  enough  to  fill  half 
the  abdominal  cavity. 

These  aneurisms  are  of  interest  to  the  surgeon  for  the  reason  that 
they  constitute  one  of  the  later  complications  of  a  kidney  trauma, 
and  also  for  the  reason  that  they  are  often  extremely  difficult  to 
diagnosticate,  owing  to  the  frequent  absence  of  the  classic  signs  of 
aneurism,  pulsation,  thrill,  and  bruit.  They  are  important  for  the 
reason  that  they  tend  to  an  invariable  fatal  termination  unless  relieved 
by  surgical  operation. 

Symptoms. — The  chief  symptoms  are  tumor  and  hematuria.  The 
tumor  may  develop  rapidly  01  slowly  according  to  the  size  of  the 
ruptured  vessel  or  the  resistance  of  the  surrounding  tissue.     It  is 


606  DISEASES  OF   THE  KIDNEYS  AND   URETERS 

not,  as  a  rule,  movable,  and  is  rarely  tender.  Hematuria  is  present 
in  the  majority  of  cases,  and  may  be  continuous  or  intermittent. 

The  persistence  of  hematuria  after  an  injury  and  the  occurrence  of 
a  progressively  increasing  tumor  in  the  flank  without  other  symptoms 
should  suggest  the  possibility  of  false  aneurism. 

Treatment. — The  treatment  should  be  nephrectomy  and  complete 
removal  of  the  sac.  This  in  large  tumors  is  accompanied  by  grave 
danger  of  hemorrhage  and  shock.  It  should  be  accomplished  through  a 
large  incision  or  by  the  combined  lumbar  and  abdominal  route,  the 
advantage  of  the  abdominal  opening  being  to  secure  more  easily  the 
vessels  of  the  pedicle. 

Movable  Kidney. — Slight  vertical  mobility  of  the  kidney  is  present 
normally,  but  this  cannot,  as  a  rule,  be  appreciated  by  palpation  except 
in  cases  of  marked  emaciation  or  abnormal  laxity  of  the  abnormal  wall. 

The  kidney  is  held  in  position  by  its  vascular  connections  with  the 
aorta  and  vena  cava;  by  the  so-called  perinephric  fascia,  which  is 
simply  a  separation  into  two  layers  of  the  posterior  portion  of  the 
transversalis  or  deep  fascia  of  the  abdomen,  which  invests  the  kidney 
and  its  fatty  envelope  in  a  kind  of  secondary  capsule;  by  the  perirenal 
fat;  by  its  anterior  peritoneal  adhesions,  and  by  pressure  of  other 
abdominal  organs. 

The  causes  which  are  mostly  responsible  for  abnormal  mobility 
of  this  organ  are:  wasting  diseases,  causing  absorption  of  the  perirenal 
fat;  frequent  pregnancies,  the  removal  of  large  tumors  or  collections 
or  ascitic  fluids,  causing  laxity  of  the  abdominal  walls;  ptosis  of  other 
organs;  congenital  or  acquired  relaxation  of  the  peritoneal  and  fascial 
connections,  and,  rarely,  trauma.  In  the  majority  of  instances 
movable  kidney  occurs  in  tall,  long-waisted,  thin  women.  Becker 
and  Lenhoff  observed  this  so  frequently  that  they  were  able  to  predict, 
from  the  general  appearance  and  certain  measurements  of  a  patient, 
whether  or  not  the  kidney  could  be  palpated.1  M.  L.  Harris  believes 
that  in  this  type  of  individual,  contraction  of  the  space  immediately 
below  the  diaphragm,  by  straining,  coughing,  or  body  movements, 
causes  pressure  upon  the  upper  pole  of  the  kidney,  and  thus  forces  it 
downward. 

The  frequency  of  movable  kidney  is  variously  estimated  to  be 
from  4  to  40  per  cent,  of  all  individuals.  Eight-tenths  of  the  cases 
occur  in  women.  The  writer  found  it  present  to  a  pathologic  degree 
in  11  of  a  series  of  200  living  subjects  examined  without  reference  to 
symptoms,  and  in  14  of  150  subjects  examined  in  the  dissecting-room 
of  the  College  of  Physicians  and  Surgeons  the  kidney  was  found  to  be 
freely  movable  or  out  of  its  normal  position. 

The  association  of  movable  kidney  with  general  enteroptosis  is 

1  The  index  of  the  body  form  was  obtained  by  dividing  the  distance  from  the  supra- 
sternal notch  to  the  symphysis  pubis,  by  the  least  circumference  of  the  abdomen,  and 
multiplying  it  by  100.  If  the  result  was  above  77  the  kidney  generally  could  be  palpated; 
if  below  75,  it  could  not. 


INJURIES  OF  THE  KIDNEY  607 

occasionally  seen,  and  presents,  as  a  rule,  a  fairly  typical  clinical 
picture;  but  this  association,  said  by  Glenard  to  be  constant,  has 
not  been  found  so  frequently  by  subsequent  observers. 

The  method  of  determining  the  presence  of  a  movable  kidney 
is  to  place  the  patient  in  the  dorsal  position  on  a  hard  mattress  or 
table.  The  abdominal  muscles  should  be  relaxed  by  drawing  up 
the  legs.  One  hand  of  the  examiner  should  be  placed  in  the  costo- 
vertebral angle,  the  other  flatly  laid  over  the  rectus  muscle  near  its 
attachment  to  the  costal  cartilages.  By  gently  approximating  the 
two  hands  and  instructing  the  patient  to  take  a  deep  inspiration, 
the  kidney  if  abnormally  movable  easily  can  be  felt  by  the  hand  of 
the  examiner  except  in  cases  of  great  obesity  or  muscular  rigidity. 

It  is  convenient  to  describe  three  degrees  of  mobility.  A  kidney 
is  said  to  be  palpable  when  the  lower  pole  can  be  felt  by  the  examiner 
during  deep  inspiration;  movable,  when  the  entire  kidney  can  be 
palpated;  and  floating,  when  it  can  be  grasped  and  moved  about  by 
the  hand  or  makes  extensive  excursions  to  the  pelvis  or  other  portions 
of  the  abdominal  cavity. 

Symptoms.- — In  the  majority  of  instances  no  symptoms  accompany 
this  condition,  the  discovery  of  a  movable  kidney  being  made  by 
accident  or  during  the  course  of  a  systematic  abdominal  examination. 
When  present  the  symptoms  may  be  classified  as  digestive,  neuras- 
thenic and  renal.  The  digestive  symptoms  may  or  may  not  have  an 
organic  basis.  Traction  on  the  duodenum  or  kinking,  might  give 
rise  to  pyloric  stenosis;  and  an  associated  gastroptosis  might  cause 
diminished  motility;  but  these  are  not  the  symptoms  which  usually 
accompany  movable  kidney.  The  digestive  symptoms  ordinarily 
present  have  generally  a  strong  neurasthenic  flavor.  Vague  pains  before 
or  after  meals,  in  the  epigastrium  or  substernal  region,  right  or  left 
iliac  fossa,  over  the  ovary,  appendix  or  gall-bladder,  occurring  at  no 
regular  time  and  changing  in  character  and  position  each  day.  Areas 
of  marked  abdominal  tenderness  to  even  the  gentlest  pressure,  these 
also  changing  their  position  daily  and  with  each  medical  examination; 
a  prominent  aorta  with  exaggerated  pulsation,  pelvic  pain,  constipation, 
menstrual  disturbances,  nausea,  gas,  cribbing,  parasthesias,  and  emo- 
tional instability.  Of  the  definite  renal  symptoms  which  may  be  caused 
by  movable  kidney,  that  group  known  as  Dietls'  crisis  is  the  most  char- 
acteristic. It  is  caused  by  a  transitory  hydronephrosis  due  to  ureteral 
obstruction  from  kinking,  the  result  of  a  marked  descent  of  the  organ  or 
forward  rotation.  Acute  renal  hyperemia  might  easily  be  produced 
by  a  similar  twisting  of  the  vascular  pedicle,  and  may  be  an  element 
in  the  symptom  complex.  Pain,  sudden  and  severe,  occurring  in  the 
epigastrium  or  lumbar  region,  radiating  downward  along  the  course  of 
the  ureter  to  the  testicle  or  penis.  Nausea,  vomiting,  weakness, 
collapse,  and  the  presence  of  a  tender  renal  tumor,  which  suddenly 
disappears  with  active  diuresis  and  complete  relief  of  pain.  These 
attacks  occur  at  irregular  intervals,   and  occasion  great   suffering. 


608  DISEASES  OF   THE   KIDNEYS  AND   URETERS 

The  duration  of  symptoms  is  exceedingly  variable.  Another  definite 
symptom  of  movable  kidney  may  be  a  more  or  less  constant  dragging 
pain  over  the  gall-bladder  or  liver  from  traction  on  the  peritoneal 
folds  connecting  these  organs. 

Prognosis. — Relief  to  the  purely  local  renal  symptoms  may  be 
looked  for  if  the  condition  can  be  corrected  by  apparatus  or  operation. 
If  the  symptoms,  however,  are  largely  those  of  neurasthenia,  malnutri- 
tion, or  indefinite  disorders  of  digestion,  with  vague  pains  in  the 
abdomen  or  pelvis,  the  prognosis  should  be  guarded.  The  writer 
has  observed  that  in  a  large  proportion  of  the  neurotic  cases,  operation 
has  proved  of  no  value,  and  in  not  a  few  the  condition  has  been 
aggravated  by  the  addition  of  a  traumatic  neurasthenia. 

Treatment. — In  cases  in  which  the  mobility  of  the  kidney  is  appar- 
ently due  to  absorption  of  the  perirenal  fat,  the  rest-cure,  with  a 
generous  diet  made  up  largely  of  the  carbohydrates,  will  often  be 
of  value.  If  this  method  is  followed,  absolute  rest  in  bed  must  be 
insisted  upon  for  at  least  six  weeks.  The  use  of  pads  and  abdominal 
binders  may  be  tried,  but  there  is  little  reason  to  suppose  that  they 
accomplish  much  in  these  cases.  The  best  method  is  to  apply  even 
compression  over  the  entire  abdomen  by  means  of  an  elastic,  tightly 
fitting  corset,  as  advised  by  Israel.  Gallant  obtains  satisfactory 
results  by  the  use  of  the  modern  straight  front  corset  applied  in  the 
morning  before  leaving  bed.  The  corset  should  be  two  sizes  smaller 
than  usual,  and  should  be  snugly  applied  with  the  patient  on  the  back, 
the  hips  being  elevated. 

In  the  great  majority  of  cases,  however,  nephrorrhaphy  is  the  method 
of  choice,  and  should  be  advised  in  all  instances  where  the  lesion  results 
in  a  definite  Dietl's  crisis,  or  where  the  painful  local  symptoms  can 
be  rationally  attributed  to  peritoneal  traction  or  hyperemia  of  the 
organ. 

INFLAMMATORY  DISEASES  OF  THE  KIDNEY. 

Renal  Suppuration. — Renal  suppuration  may  arise  from  infection 
conveyed  to  the  organ  directly  by  a  penetrating  wound,  by  extension 
from  a  neighboring  focus,  by  an  ascending  process  from  the  lower 
urinary  passages,  or  by  the  blood  current. 

The  first  two  methods  are  exceedingly  rare;  the  last  two  of  frequent 
occurrence.  Considerable  difference  of  opinion  in  the  past  has  existed 
among  surgeons  regarding  the  comparative  frequency  of  ascending 
and  blood  infections  of  the  kidney,  and  while  all  agree  that  ascending 
affections  are  of  fairly  frequent  occurrence,  the  majority  of  the  grave 
suppurating  lesions  of  the  organ  are  now  generally  admitted  to  be 
of  hematogenous  origin.  As  both  methods  of  infection  may  give  rise 
to  practically  the  same  clinical  types  of  diseases,  a  brief  description  of 
each  may  be  in  order  before  taking  up  the  individual  diseases. 

Ascending  Infections. — Ascending  infections  are  favored  by  any 
interference  with  the  normal  outflow  of  urine  from  the  bladder;  they 


INFLAMMATORY  DISEASES  OF   THE  KIDNEY  609 

arc  also  favored  by  any  factor  which  results  in  forcing  the  ureteric 
sphincter,  allowing  a  reflux  of  contaminated  urine  in  the  ureter;  or 
in  a  diminished  resistance  on  the  part  of  the  individual.  Albarran 
has  shown  that  cultures  of  the  most  virulent  micro-organisms  may, 
with  impunity,  be  injected  into  the  bladders  of  dogs  as  long  as  there  is 
no  obstruction  to  the  normal  outflow  of  urine,  but  that  a  fatal  pyelo- 
nephritis results  if  an  artificial  retention  is  produced  by  ligation  of  the 
urethra.  It  is  likewise  well  known  that  in  the  aged  and  in  those  whose 
resistance  has  been  greatly  diminished  by  dissipation  and  disease, 
involvement  of  the  kidneys  is  far  more  frequent  from  the  extension 
upward  of  an  infection  of  the  bladder  or  urethra  than  in  young  subjects 
and  those  who  enjoy  robust  health. 

Given,  therefore,  a  .case  of  acute  or  chronic  retention  of  urine  from 
stricture,  prostatic  abscess  or  senile  enlargement;  and  add  to  this, 
infection,  from  the  extension  backwards  of  a  gonorrhea,  or,  introduced 
by  the  passage  of  an  unclean  instrument,  and  we  have  the  conditions 
favoring  an  ascending  infection.  The  first  result  is  an  active  cystitis, 
which  is  soon  followed  by  an  extension  of  the  inflammation  to  the 
renal  pelvis,  where  it  rapidly  ascends  the  straight  tubules,  and  results 
in  multiple  foci  of  infection  in  the  cortex  and  acute  degeneration  of  the 
epithelium  of  the  tubules  and  glomeruli.  This  not  infrequently  causes 
a  complete  suspension  of  the  renal  function,  with  death  from  a  com- 
bination of  uremia  and  sepsis.  In  certain  instances  the  ureteral  mucous 
membrane  apparently  takes  no  part  in  the  process,  the  infection 
reaching  the  kidney  by  means  of  the  periureteral  lymphatics. 

The  presence  of  a  ureteral  calculus  or  new  growth,  of  a  tuberculous 
area  of  the  trigone,  or  any  other  factor  which  causes  severe  vesical 
tenesmus  and  interferes  with  the  normal  sphincteric  action  of  the  lower 
end  of  one  ureter,  will  act  as  a  predisposing  cause  of  unilateral  renal 
infection. 

In  the  milder  types  of  ascending  infection  the  process  may  be 
arrested  at  any  point.  The  terminal  condition,  therefore,  may  be 
pyelitis,  pyelonephritis,  pyonephrosis,  cortical  abscess,  or  perinephritis. 

Hematogenous  Infections. — Hematogenous  infections  of  the  kidney 
are  produced  by  pathogenic  micro-organisms  conveyed  to  the  organ 
by  the  blood  current.  It  is  a  well-known  and  generally  accepted  fact 
that  during  the  progress  of  any  acute  infectious  or  septic  disease, 
certain  micro-organisms,  giving  rise  to  the  symptoms,  find  their  way 
into  the  blood  current,  and  are  either  destroyed  by  the  bactericidal 
action  of  the  blood  itself,  or  by  substances  encountered  in  the  passage 
of  the  blood  through  certain  organs,  or  they  are  excreted  through 
the  kidneys.  Pernice  and  Scagliosi,  in  Virchow's  Archiv,  1894, 
give  the  results  of  an  elaborate  series  of  experiments,  showing  the 
anatomic  changes  occurring  in  the  kidney  by  the  excretion  of  various 
pathogenic  and  non-pathogenic  bacteria. 

Albarran,  in  1889,  reviewed  the  entire  subject  of  renal  infection, 
and  concluded  that  pathogenic  bacteria  may,  under  certain  conditions, 
39 


610  DISEASES  OF   THE  KIDNEYS  AND   URETERS 

be  eliminated  through  the  kidneys  without  producing  marked  anatomic 
lesions;  their  elimination,  on  the  other  hand,  may  give  rise  to  a  bac- 
terium, to  a  glomerular  nephritis  with  degeneration  of  the  epithelium, 
to  multiple  non-pyogenic  infarcts,  to  pyogenic  infarcts  or  multiple 
abscesses,  to  perinephritic  abscess,  to  pyelonephritis,  or  to  a  rapidly 
fatal  toxemia.  Pie  also  stated  that  the  effects  of  trauma,  excessive 
functional  activity,  the  presence  of  toxic  products,  and  renal  retention, 
all  served  to  accentuate  the  process  and  to  favor  the  formation  of 
graver  lesions. 

The  lesions  most  commonly  found  in  these  cases  are  due  to  a  plugging 
of  the  smaller  arteries  and  capillary  vessels  with  groups  of  organisms. 
These  minute  emboli  are  later  surrounded  by  a  zone  of  round-cell 
infiltration.  Where  the  larger  trunks  are  thus  involved,  triangular 
infarcts  are  produced;  where  the  capillaries  only  are  involved,  minute 
abscesses  are  seen  throughout  the  cortex  and  beneath  the  capsule. 
If  the  process  progresses,  the  bacterial  emboli  are  rarely  recognized; 
only  areas  of  necrosis  or  purulent  infiltration  are  apparent. 

At  a  still  later  stage  many  of  these  collections  of  pus  coalesce, 
forming  larger  parenchymatous  abscesses,  which  may  rupture  through 
the  capsule,  giving  rise  to  perinephritis,  or  into  the  pelvis,  giving  the 
typical  picture  of  pyelonephritis. 

It  will  thus  be  seen  that  both  the  ascending  and  the  blood  infections 
may  give  rise  to  lesions  which,  on  gross  inspection,  appear  identical, 
and  each  may  result  in  three  degrees  or  types  of  infection:  the  acute 
or  fulminating,  often  rapidly  fatal;  the  subacute,  progressing  slower 
and  resulting  in  the  classical  types  of  renal  suppuration  as  pyelitis, 
pyelonephritis,  pyonephrosis,  perinephritis,  etc.;  and  an  exceedingly 
mild  type  which  often  recovers  spontaneously  and  presents  no  surgical 
indications. 

Acute  Ascending  Infection  of  the  Kidney. — The  commonest  type 
of  this  variety  of  renal  infection  is  seen  in  the  aged  victims  of  chronic 
urinary  obstruction  from  old  urethral  stricture  or  prostatic  hyper- 
trophy. In  these  cases  the  bladder  often  is  enormously  dilated  with 
both  ureteral  sphincters  open,  or  easily  forced  by  severe  straining  or 
tenesmus.  Into  this  bladder,  infection  may  be  introduced  by  the 
first  passage  of  a  catheter,  often  for  purposes  of  diagnosis.  When  this 
occurs,  death  frequently  results  within  ten  days,  from  acute  bilateral 
pyelonephritis. 

Diagnosis. — In  these  cases  the  symptoms  are  characteristic,  but  often 
fail  to  impress  a  careless  medical  observer  as  being  due  to  renal  infec- 
tion on  account  of  the  absence  of  lumbar  pain.  The  first  relief  from 
the  bladder  distension  is  followed  by  a  short  period  of  freedom  from 
all  symptoms,  then  follows  a  chill  with  rapidly  rising  temperature, 
headache,  anorexia,  great  weakness  and  a  diminished  secretion  of 
urine.  Later  the  urine  appears  smoky  and  finally  suppression 
occurs  with  delirium,  coma,  and  death.  In  these  rapidly  fatal 
cases  both  kidneys  are  involved  in  the  process.     In  a  few  instances 


PLATE   XXI 


Acute  Hematogenous  Infection  of  Kidney. 

Organ  bisected,  showing  anterior  and   posterior  surfaces. 
(Lumiere    Photograph.) 


INFLAMMATORY  DISEASES  OF  THE   KIDNEY  (ill 

the  infection  seems  either  limited  to  one  kidney  or  the  second  kidney 
is  but  slightly  involved.  In  these  cases  the  symptoms  are  those  of  a 
rapidly  advancing  sepsis  without  suppression  of  urine;  and  if  the 
process  continues  sufficiently  long,  signs  of  a  unilateral  septic  kidney 
may  result,  as  localized  pain,  tenderness  and  possibly  the  presence  of 
a  sensitive  renal  tremor.  Cystoscopy  and  ureteral  catheterization  may 
aid  greatly  in  the  diagnosis  and  in  furnishing  indications  for  treatment. 

Prognosis. — Except  in  the  rare  unilateral  cases,  the  prognosis  in 
this  acute  fulminating  type  is  exceedingly  grave.  In  the  unilateral 
cases  life  sometimes  may  be  saved  by  a  timely  operation. 

Treatment. — In  the  bilateral  cases,  the  indications  are  to  drain  the 
bladder,  and  to  administer  diuretics  and  urotropin.  Proctoclysis  by  the 
Murphy  drip  method,  and  intravenous  saline  infusions  are  of  value, 
and  the  question  of  double  renal  decapsulation  may  be  considered. 
In  the  unilateral  type  nephrotomy  with  drainage  or  nephrectomy  may 
be  employed  in  suitable  cases. 

Acute  Unilateral  Hematogenous  Infection  of  the  Kidney. — While 
most  surgeons  of  experience  appreciate  the  relationship  between 
hematogenous  infection  and  the  easily  recognized  advanced  types 
of  renal  suppuration,  three  important  facts  regarding  the  behavior 
of  this  variety  of  infection  are  not  generally  appreciated  by  the  pro- 
fession. The  first  is  that  the  lesions  are  often  unilateral;  the  second, 
that  in  the  severest  type  of  the  affection  the  toxemia  is  so  overwhelming 
that  death  often  occurs  before  any  characteristic  renal  symptoms  are 
developed;  and  the  third  is  that  these  cases,  in  their  early  sympto- 
matology, vary  greatly,  the  clinical  picture  often  suggesting  an  acute 
grip,  lobar  pneumonia,  appendicitis,  or  cholecystitis. 

These  facts  would  warrant  a  separate  consideration  of  the  acute 
fulminating  type,  which,  by  its  symptom  complex,  deserves  recognition 
as  a  distinct  pathologic  entity.  Two  factors  are  necessary  for  the 
production  of  this  type  of  renal  lesion:  (1)  A  septic  focus  somewhere 
in  the  body  capable  of  furnishing  a  certain  number  of  pathogenic 
bacteria  to  the  blood  current;  and  (2)  a  diminished  resistance  on  the 
part  of  one  kidney  due  to  trauma,  the  presence  of  a  calculus,  an 
obstructed  ureter,  or  a  previous  septic  lesion.  The  disease,  therefore, 
not  infrequently  follows  pneumonia,  tonsillitis,  any  of  the  exanthemata, 
typhoid  fever,  a  furuncle,  or  possibly  obstinate  constipation,  as  the 
colon  bacillus  often  is  the  offending  organism. 

Over  SO  per  cent,  of  the  cases  are  observed  in  women,  and  in  a  large 
majority  of  instances  the  right  kidney  is  the  one  affected. 

In  the  severest  cases  the  perirenal  fat  and  areolar  tissue  are  edema- 
tous, the  kidney  moderately  enlarged  and  deeply  congested.  The 
surface  is  studded  with  deep  red,  elevated  areas  or  groups  of  miliary 
abscesses.     Plate  XXI. 

On  section  one  or  more  triangular  infarcts  may  be  seen  with  numerous 
necrotic  areas  and  suppurative  foci.  There  is  marked  cloudy  swelling 
of  the  cortex  (Fig.  290). 


612 


DISEASES  OF   THE  KIDNEYS  AND   URETERS 


The  organisms  most  frequently  obtained  by  culture  from  these 
lesions  are  the  colon  bacillus,  bacillus  typhosus,  streptococcus  pyogenes, 
and  staphylococcus  aureus.  The  author  has  been  able  to  reproduce 
these  lesions  in  animals  by  all  of  the  above-mentioned  organisms,  and 
also  by  the  pneumococcus  and  bacillus  pyocyaneus. 

Diagnosis. — The  disease  may  or  may  not  be  ushered  in  by  a  chill. 
When  present  it  generally  indicates  a  severe  type  of  infection.  The 
initial  rise  of  temperature  is  high,  generally  104°  or  105°  F.;  the  pulse 
is  frequently  120  or  more.     The  toxemia  is  marked  from  the  first  and, 


Fig.  290. — Acute  septic  infarcts  of  kidney.     (Blake. ) 

with  the  high  fever,  suggests  often  an  acute  grip,  lobar  pneumonia 
or  one  of  the  exanthemata.  Then  follows  a  more  or  less  vague  pain 
in  the  abdomen  or  flank  corresponding  to  the  side  of  the  lesion.  Ten- 
derness and  muscular  rigidity  over  the  region  of  the  appendix  or  gall- 
bladder leads  often  to  error  in  believing  one  of  these  organs  to  be  the 
seat  of  disease.  As  the  urinary  secretion  from  the  infected  kidney  is 
greatly  diminished  and  is  largely  diluted  by  the  abundant  secretion 
from  the  unaffected  organ,  the  mixed  urine,  when  passed  or  drawn  from 
the  bladder,  is  often  quite  normal  in  appearance,  and  the  slight  trace 
of  albumin,  blood,  and  pus  is  often  overlooked  unless  a  more  than 


INFLAMMATORY  DISEASES  OF  THE  KIDNEY  613 

ordinarily  careful  examination  is  made.  The  one  pathognomonic  sign 
present  in  all  cases  is  a  marked  unilateral  costovertebral  tenderness. 

Prognosis. — In  regard  to  prognosis  it  may  be  stated  that  in  the 
severe  cases  death  almost  invariably  occurs  unless  the  symptoms 
are  promptly  arrested  by  nephrectomy.  Many  of  the  less  severe 
cases,  if  untreated,  go  on  to  the  development  of  the  gross  suppurative 
lesions  to  be  considered  in  the  next  section,  while  many  of  the  mildest 
type  recover  spontaneously. 

Treatment. — In  regard  to  treatment,  the  cases  should  be  divided 
into  three  classes : 

The  severe  type,  in  which  the  temperature  remains  high  and  the 
toxemia  is  rapidly  progressive.  These  cases  require  nephrectomy  at 
the  earliest  possible  moment.  The  milder  eases  are  those  in  which 
the  initial  temperature  may  be  high,  but  begins  to  fall  within  forty- 
eight  hours,  and  where  the  toxemia  is  less  marked.  These  cases 
often  may  be  successfully  treated  by  decapsulation,  which  relieves  the 
intense  congestion  and  allows  nature  to  complete  the  reparative 
process.  Where  one  or  more  cortical  abscesses  are  present,  they  should 
be  opened  and  drained. 

In  the  mildest  type  the  case  may  be  treated  expectantly  with  a 
reasonable  prospect  of  complete  recovery,  although  the  writer  has 
observed  two  or  three  patients  in  which  a  chronic  nephritis  or 
pyelonephritis  has  remained. 

Pyelitis. — Pyelitis  is  an  inflammation  of  the  pelvis  of  the  kidney 
and  ureter,  caused  by  infection  from  the  rupture  of  a  septic  focus  in 
the  kidney-substance,  or  from  an  extension  upward  of  infection  from 
the  bladder  and  lower  urinary  passages.  The  author  never  has 
been  convinced  that  suppurative  pyelitis  ever  arises  spontaneously, 
or  that  a  blood  infection  of  the  renal  pelvis  ever  occurs  without  lesions 
in  the  kidney  substance. 

In  the  majority  of  cases  pyelitis  is  accompanied  b}'  nephritis,  and 
to  this  condition  the  term  yyeloneyhritis  should  be  applied.  Morris 
has  described  a  form  of  non-suppurative  pyelonephritis,  in  which  the 
lesion  of  the  renal  parenchyma  consists  in  an  acute  toxic  but  non- 
suppurative interstitial  inflammation.  This  is  present  in  a  fair 
proportion  of  the  cases  of  pyelitis,  and  may  seriously  compromise 
the  renal  function.  By  far  the  greater  number  of  these  cases  arise 
from  infection  from  below,  due  to  contamination  of  the  bladder  through 
the  introduction  of  instruments  or  to  extension  upward  of  a  gonorrheal 
urethritis.  In  these  instances  the  disease  is  frequently  bilateral. 
Conditions  which  favor  kidney  infection  in  this  manner  are:  back 
pressure  of  urine  from  obstructive  disease  of  the  prostate  or  urethra, 
mobility  of  the  kidney,  and  the  presence  of  calculus. 

Symptoms. — In  uncomplicated  pyelitis  the  symptoms  are:  fever, 
lumbar  pain,  vesical  irritability,  and  occasionally,  a  diminished  secre- 
tion of  urine  containing  albumin,  casts,  pus,  and  blood.  Suppression 
of  urine,  delirium,  and  stupor  may  follow  if  the  kidney  parenchyma 


614  DISEASES  OF  THE  KIDNEYS  AND    URETERS 

is  extensively  involved,  and  the  attack  ends  fatally  in  a  few  days. 
In  the  milder  cases  the  patient  may  live  through  the  acute  stage  and 
pass  into  one  of  chronic  pyelonephritis,  in  which  the  only  evidence 
of  disease  may  be  the  presence  of  albumin  and  pus  in  the  urine.  This 
condition  may  be  present  for  years,  the  patients  apparently  enjoying 
fair  health,  but  a  recurrence  of  the  acute  symptoms  may  be  expected 
to  follow  renewed  irritation  of  the  lower  urinary  passages,  the  abuse 
of  alcohol,  or  the  administration  of  an  anesthetic.  In  the  milder 
cases,  especially  if  of  gonorrheal  origin,  complete  recovery  may  take 
place. 

Treatment. — The  treatment  should  consist  of  rest  in  bed,  diuretics, 
and  the  internal  administration  of  urotropin  in  doses  of  from  5  to  15 
grains  two  or  three  times  a  day,  taken  in  large  quantities  of  water. 
The  symptoms  of  uremia  must  be  controlled  by  free  catharsis  and 
diaphoresis,  those  of  sepsis  by  heart  tonics  and  supporting  measures. 
The  use  of  prolonged  rectal  irrigation  with  normal  salt  solution,  or 
intravenous  infusions  of  the  same  agent,  are  often  followed  by  the 
most  satisfactory  results,  both  on  the  circulation  and  the  function  of 
the  kidneys. 

Suppurative  Pyelonephritis. — In  this  disease  the  infection  is  a 
pyogenic  one,  and  results  in  the  formation  of  multiple  foci  of  suppura- 
tion in  the  parenchyma  of  the  kidney.  These  may  coalesce  and  form 
one  or  more  large  abscesses,  or  the  entire  organ  may  be  honeycombed 
with  suppurating  areas.  As  in  the  non-suppurative  form  of  the  disease, 
the  infection  may  reach  the  kidney  by  an  upward  extension  from  the 
lower  urinary  passages,  or  it  may  be  the  result  of  infection  conveyed 
to  the  organ  by  the  blood  from  some  distant  focus.  In  the  former 
event  the  disease  is  generally  bilateral,  in  the  latter  more  often  it  is 
unilateral.  It  occasionally  happens,  as  pointed  out  by  Alexander 
Johnson,  that  in  many  bilateral  cases  the  chief  destructive  lesion 
frequently  is  located  in  one  kidney;  and  that  the  impaired  functional 
activity  of  the  other  may  be  largely  due  to  the  coexisting  toxemia. 

Symptoms. — The  symptoms  of  this  condition  are  practically  the  same 
as  in  the  non-suppurative  form  of  the  disease,  with  the  addition  of  a 
more  marked  pyuria,  leukocytosis,  and  the  presence  often  of  fever  and 
a  tender  kidney  tumor. 

Abscess  of  the  Kidney. — Abscess  of  the  kidney-substance  may  occur 
independently  or  in  connection  with  suppurative  pyelonephritis.  It 
may  be  caused  by  the  coalescence  of  several  small  foci  of  suppuration, 
may  arise  from  a  septic  embolus,  or  from  the  infection  of  a  single 
blood-clot  or  mass  of  damaged  tissue  due  to  trauma.  As  in  the  former 
condition,  the  infection  reaches  the  organ  through  the  blood  or  from 
the  lower  urinary  organs.  The  association  of  abscess  of  the  kidney 
and  calculus  has  been  frequently  noted.  One  or  both  kidneys  may  be 
involved.  One  abscess  only  may  be  present,  or  several  may  occur  in 
the  same  kidney.  As  the  disease  advances  the  normal  tissue  of  the 
kidney  is  destroyed,  and  if  the  progress  is  not  arrested  this  leads  to  an 


INFLAMMATORY  DISEASES  OF  THE  KIDNEY  615 

opening  either  into  the  renal  pelvis  or  through  the  capsule  into  the 
perirenal  tissues.  In  the  former  event  the  disease  may  be  cured 
spontaneously,  in  the  latter  a  perinephritic  suppuration  results. 

Symptoms. — The  course  of  the  disease  may  be  acute  or  subacute; 
in  the  acute  forms  the  clinical  picture  is  one  of  acute  progressive 
sepsis  accompanied  by  pain  in  the  affected  side  and  a  diminished 
secretion  of  urine.  The  urine  may  be  albuminous,  but  contains  no 
appreciable  quantity  of  pus  unless  the  abscess  ruptures  into  the 
pelvis.  There  is  a  marked  leukocytosis,  and  hematuria  may  be 
present.  Examination  may  reveal  the  presence  of  a  renal  tumor, 
but  this  is  not  common.  Tenderness  is  generally  present  and  often 
muscular  rigidity.  If  the  condition  is  accompanied  by  perinephritis, 
there  are  edema  and  induration  in  the  flank,  and  later  fluctuation 
may  be  detected. 

Prognosis. — In  the  subacute  cases  the  symptoms  may  be  misleading, 
the  condition  being  diagnosticated  typhoid  fever  or  malaria.  This 
mistake,  however,  should  never  occur  if  a  blood  examination  can 
be  made. 

In  the  severe  cases,  if  unrelieved  by  surgical  means  or  by  spontaneous 
rupture,  death  may  be  expected  from  sepsis  within  two  or  three 
weeks.  The  spontaneous  evacuation  of  the  pus  into  the  pelvis,  ureter, 
or  intestine,  may  result  in  a  sudden  and  complete  disappearance  of 
the  symptoms,  and  recovery  may  follow  without  further  treatment. 

Pyonephrosis. — -This  condition  may  represent  the  terminal  stage  of 
any  acute  suppurative  process  in  the  kidney.  It  is  generally  unilateral 
and  consists  in  a  dilatation  of  the  renal  pelvis  with  pus  from  plugging 
of  the  ureter  with  a  calculus,  a  bit  of  fibrin,  or  clot  of  blood;  or  it 
may  result  from  the  infection  of  a  hydronephrosis.  In  either  event 
the  kidney-substance  is  quickly  destroyed  both  by  the  pressure  of 
the  accumulated  fluid  and  the  destructive  tendency  of  the  infection. 

Symptoms. — The  symptoms  are  acute  pain  and  tenderness  in  the 
flank,  with  chills,  fever,  sweats,  and  general  prostration.  The  urine 
may  be  negative;  blood  examination  reveals  a  marked  increase  in 
the  leukocytes.  On  physical  examination  a  tender  tumor  generally 
can  be  found  in  the  lumbar  region,  which  is  oval,  elastic,  and  may 
move  slightly  with  respiration.  It  is  best  appreciated  by  bimanual 
palpation,  and  generally  can  be  demonstrated  to  lie  behind  the  colon. 

Treatment  of  Suppurative  Disease  of  the  Kidney. — There  is  a  grow- 
ing tendency  among  surgeons  to  employ  more  radical  measures  in  the 
treatment  of  the  suppurative  diseases  of  the  kidney.  Formerly 
pyelonephritis  was  regarded  as  beyond  the  reach  of  surgical  relief  for 
the  reason  that  the  lesion  was  supposed  always  to  be  bilateral,  and 
the  treatment  of  kidney  abscess  and  pyonephrosis  was  limited  to 
incision  and  drainage,  postponing  to  a  later  period  the  nephrectomy 
which  generally  was  found  to  be  necessary.  It  was  held  by  many 
that  secondary  nephrectomy  was  a  far  safer  operation  than  immediate 
removal  of  the  organ.     Recent  observations,  however,  have  shown  that 


616      DISEASES  OF  THE  KIDNEYS  AND   URETERS 

in  the  majority  of  instances  better  results  can  be  obtained  by  primary 
nephrectomy  in  these  hopelessly  diseased  kidneys  than  by  nephrotomy, 
which  rarely  results  in  a  cure,  and  which  always  leaves  behind  a  focus 
of  infection  which  may  result  in  a  persistent  sinus  and  prevent  complete 
recovery  from  the  sepsis.  Nephrotomy  is  indicated  in  conditions  of 
grave  sepsis  in  which  prolonged  operation  would  be  fatal;  but  in  these 
cases  the  secondary  nephrectomy  should  be  performed  as  soon  as  the 
condition  of  the  patient  permits,  as  adhesions  soon  form  which  often 
render  the  secondary  nephrectomy  an  exceedingly  difficult  and  dan- 
gerous procedure. 

When  nephrotomy  is  employed,  the  kidney  should  be  exposed 
by  a  lumbar  incision,  the  suppurating  cavity  opened  by  an  incision 
through  the  convex  border,  the  finger  introduced,  and  all  septa  broken 
down,  allowing  free  drainage,  which  should  be  maintained  by  the  use 
of  a  large  rubber  drainage  tube  introduced  into  the  suppurating 
cavity  and  surrounded  by  a  snug  gauze  packing  to  guard  against 
hemorrhage,  which  is  often  severe  and  controlled  with  difficulty. 
In  all  operations  upon  cases  of  acute  renal  sepsis  the  surgeon  should 
aim  to  complete  his  operation  in  the  shortest  time  compatible  with 
accurate  work,  as  prolonged  anesthesia  and  exposure  on  the  operating- 
table  may  seriously  interfere  with  the  function  of  the  remaining 
kidney,  perhaps  already  compromised  by  the  coexisting  toxemia. 

In  all  such  cases  it  has  been  the  writer's  custom  to  administer  an 
intravenous  infusion  of  from  500  to  1500  cc.  of  normal  salt  solution 
immediately  after  operation  with  a  view  to  increasing  the  activity 
of  the  skin  and  of  the  remaining  kidney. 

Perinephritic  Abscess. — Perinephritis  or  perinephritic  abscess  is  an 
inflammation  of  the  retroperitoneal  connective  tissue  surrounding 
the  kidney.  This  may  arise  from  an  infection  derived  from  the  kidney 
or  bowel,  from  the  blood,  or  from  the  lymphatics;  or  it  may  result 
from  the  introduction  of  infectious  material  from  without  by  means 
of  a  penetrating  wound.  It  is  commonly,  therefore,  associated  with 
suppuration  or  trauma  of  the  kidney,  ulcer  of  the  large  intestine, 
appendicitis,  inflammatory  processes  in  the  pelvis,  spine,  or  extremities; 
or  occurs  as  a  metastatic  lesion  in  general  sepsis.  The  process  may 
be  limited  to  the  region  of  the  kidney,  or  may  extend  upward  behind 
the  liver  or  downward  to  the  region  of  the  pelvic  brim  or  groin.  If 
unrelieved,  rupture  may  take  place  into  the  bowel  or  externally. 
In  one  case  of  gas  bacillus  infection  under  observation  of  the  writer 
the  pus  burrowed  downward  through  the  inguinal  canal  and  infiltrated 
the  subcutaneous  cellular  tissue,  involving  nearly  one-half  of  the 
abdominal  wall,  and  causing  extensive  necrosis  of  the  external  oblique 
muscle  and  its  aponeurosis. 

Symptoms. — The  symptoms  are  at  first  pain  in  the  kidney  region 
with  fever.  If  the  process  is  an  acute  one,  there  may  be  early  chills 
and  rapid  development  of  profound  sepsis,  with  increasing  pain  and 
tenderness  in  the  affected  side.     In  the  rare  cases  of  infection  by  the 


INFLAMMATORY  DISEASES  OF  THE  KIDNEY  017 

B.  Aerogenes  Capsulatus  which  usually  result  from  intestinal  ulcera- 
tion, the  process  is  one  of  extreme  virulence,  all  the  tissues  of  the 
abdominal  wall  becoming  quickly  involved,  as  evidenced  by  a  rapidly 
advancing  redness  and  edema  of  the  skin  with  subcutaneous  gas 
crepitus.  Generally,  however,  the  process  is  slower,  the  patient  may 
not  feel  ill  enough  to  be  in  bed,  and  may  keep  about  for  a  week  or 
longer.  In  these  instances  the  gait  is  characteristic,  the  body  is  bent 
forward  and  toward  the  affected  side,  and  the  thigh  is  never  fully 
extended  in  walking.  The  fever  gradually  rises,  the  temperature 
curve  not  infrequently  being  like  that  of  typhoid  fever.  As  the  pain 
increases,  chills  develop,  followed  by  sweats  and  prostration.  Exami- 
nation reveals  tenderness,  muscular  rigidity,  induration,  and  edema 
of  the  flank.  Blood  examination  reveals  a  high  leukocytosis.  The 
urine  may  be  negative  or  give  evidences  of  nephritis. 

The  danger  in  the  severe  cases  is  from  the  early  development  of 
a  fatal  sepsis;  in  the  milder  cases,  if  unrelieved  by  appropriate  surgical 
measures,  from  exhaustion  and  degenerative  changes  in  the  other 
organ.  Spontaneous  recovery  may  take  place  by  rupture  into  the 
bowel,  or  possibly  in  very  mild  cases  by  subsidence  of  the  inflammatory 
process  and  encapsulation  of  the  small  focus  of  pus.  In  the  rare  cases 
of  gas  bacillus  infection,  the  outlook  is  almost  hopeless — death  from 
extreme  toxemia  taking  place  often  within  forty-eight  hours. 

Treatment. — The  treatment  should  be  early  incision,  thorough 
exploration,  and  adequate  drainage.  Occasionally  a  completely 
disorganized  kidney,  large  masses  of  necrotic  tissue,  or  broken-down 
lymph  nodes  may  be  present,  and  should  be  removed.  The  best 
incision  for  this  is  the  oblique  lateral  one  described  on  page  639. 
One  or  more  counter-incisions  may  be  necessary  to  insure  adequate 
drainage. 

The  toxemia  should  be  combated  by  generous  diet,  stimulants, 
and  tonics. 

Syphilis  of  the  Kidney. — Syphilis  of  the  kidney  occurs  during  the 
secondary  and  tertiary  stages  of  the  disease. 

In  the  early  secondary  period  a  temporary  albuminuria  may  be 
present  as  in  the  case  of  other  infectious  diseases.  This  usually 
yields  to  mercurial  treatment,  or  it  may  pass  into  the  form  of  a  chronic 
interstitial  or  diffuse  nephritis.  These  chronic  forms  more  often 
develop  during  the  later  stages  of  the  disease,  and  are  not  influenced 
by  treatment. 

The  only  syphilitic  lesion  of  surgical  importance  is  the  gummatous 
nephritis  with  or  without  interstitial  changes.  This  not  infrequently 
gives  rise  to  a  distinct  enlargement  of  the  organ,  strongly  suggesting 
a  new  growth  or  tuberculosis.  Symptoms  of  this  condition  may  be 
entirely  wanting,  or  there  may  be  lumbar  pain,  hematuria,  or  vesical 
irritability.  If  the  gummatous  mass  softens  and  ruptures  into  the 
pelvis,  the  urine  may  give  evidences  of  the  disease  by  the  presence  of 
purulent  or  gummatous  matter  or  bits  of  necrotic  tissue.   The  condition 


618  DISEASES  OF   THE  KIDNEYS  AND   URETERS 

is  often  mistaken  for  tuberculosis.  In  doubtful  cases  the  Wassermann 
reaction  and  the  guinea-pig  test  may  help  to  establish  the  diagnosis. 

Treatment. — The  treatment  is  purely  medical  unless  the  disorganiza- 
tion of  the  kidney  is  so  advanced  as  to  require  nephrectomy,  which 
should  be  performed  whenever  it  is  demonstrated  that  medical  treat- 
ment fails  to  arrest  the  progress  of  the  disease. 

Tuberculosis  of  the  Kidney. — While  tuberculosis  may  occur  in  any 
part  of  the  genito-urinary  tract,  its  earliest  manifestations  appear, 
in  the  majority  of  instances,  to  take  place  in  the  kidney.  Genito- 
urinary tuberculosis  is  always  secondary,  the  infection  being  derived 
frequently  from  some  obscure  and  often  unrecognized  lesion,  as  a 
bronchial  or  mediastinal  lymph  node. 

The  infection  may  reach  the  kidney  by  the  blood  current  which 
is  common,  by  means  of  an  ascending  process  from  the  bladder,  which 
is  rare,  or  possibly  by  direct  extension  through  the  lymphatics  as 
recently  suggested  by  Brongersma  and  Hugh  Cabot.  In  the  beginning 
it  is  unilateral  in  about  80  per  cent,  of  the  cases,  and  even  in  autopsy 
reports,  freedom  from  the  disease  on  one  side,  is  demonstrated  in  from 
30  to  50  per  cent. 

In  the  hematogenous  infections,  miliary  tubercles  appear  in  the 
cortex  and  beneath  the  capsule.  These  enlarge  and  coalesce  forming 
cavities  generally  located  above  and  between  the  pyramides  which 
extend  and  often  break  into  one  of  the  calices  or  pelvis.  These  struc- 
tures in  turn  become  diseased  and  the  process  extends  downward 
along  the  ureter  to  the  bladder.  Occasionally  lesions  occur  in  the 
bladder  before  gross  changes  can  be  detected  in  the  ureter. 

In  the  ascending  type,  which  according  to  the  observations  of 
Kapsammer  occurs  but  once  to  sixty-two  cases  of  blood  infection, 
the  disease  gradually  extends  upward  along  the  ureter  until  the  pelvis 
is  reached.  This  becomes  thickened  and  ulcerated,  the  pathological 
changes  being  most  marked  at  the  upper  and  lower  pole.  From  here 
the  process  appears  to  extend  upward  along  the  straight  tubules, 
eventually  reaching  the  cortex,  where  it  may  produce  cortical  areas 
of  softening  or  abscesses  in  every  way  similar  to  those  which  result 
from  a  blood  infection. 

The  old  view  that  tuberculosis  of  the  kidney  after  extending  down- 
ward to  the  bladder  with  the  current  of  urine,  could  then  extend 
through  the  prostate  or  seminal  vesicles  along  the  van  deferens  against 
the  seminal  current  to  the  epididymis  and  testicle,  or  that  a  process 
arising  in  the  epididymis  could  eventually  reach  the  kidney  by  ascend- 
ing the  ureter  along  the  mucous  membrane  against  the  urinary  current, 
is  now  generally  abandoned.  In  those  rare  cases  in  which  the  disease 
does  ascend  the  ureter,  it  is  probably  due  to  lymphatic  extension, 
rather  than  an  ascending  process  along  the  mucous  membrane.  In 
the  ureter  as  in  the  bladder,  the  lymphatics  are  largely  situated  on 
the  outer  side  of  the  fibrous  tunic,  few  only  being  found  in  the  mucous 
membrane  or  submucous  tissue.    The  ascending  lymphatic  infections, 


INFLAMMATORY  DISEASES  OF  THE  KIDNEY  619 

therefore,  rarely  occur  except  in  those  late  cases  where  the  process 
has  involved  the  deeper  structures  of  the  bladder  wall.  When,  there- 
fore, the  second  kidney  or  a  testicle  becomes  involved  secondary  to  an 
initial  renal  focus,  it  is  probable  that  the  infection  is  hematogenous 
in  origin. 

The  fibrous  capsule  of  the  kidney  acts  as  an  effective  barrier  to  the 
extension  of  the  disease,  and  one  rarely  observes  a  tuberculous  infection 
of  the  perirenal  fatty  tissues,  although  great  thickening  of  these  tissues 
may  occur  in  cases  of  mixed  infection. 

Ureteral  obstruction  from  an  impacted  stone,  a  blood  clot,  bit  of 
necrotic  or  caseous  tissue  or  from  closure  of  the  lumen  from  edema 
or  inflammatory  thickening  of  the  ureteral  wall,  causes  pyonephrosis 
with  dilatation  of  the  pelvic  and  pressure  atrophy  of  the  renal  paren- 
chyma. 

The  course  of  the  disease  varies  greatly.  In  some  instances  of  acute 
miliary  tuberculosis  with  extensive  involvement  of  the  organs,  the 
progress  is  very  rapid  and  death  may  occur  in  a  few  weeks  or  months 
after  the  first  renal  symptom  has  been  noted.  In  the  majority  of 
cases,  however,  the  progress  of  the  disease  is  slow,  often  without  definite 
symptoms,  or  with  long  periods  of  remission;  and  in  not  a  few 
instances,  under  favorable  hygienic  conditions,  the  disease  seems  to  be 
permanently  arrested.  In  those  cases  it  is  probable  that  the  entire 
kidney  has  been  destroyed,  the  fibrous  capsule  thickened,  and  the 
caseating  mass  completely  isolated  and  often  calcified. 

Symptoms. — Tuberculous  infection  of  the  kidney  may  exist  for 
years  without  giving  rise  to  any  characteristic  renal  symptoms,  and 
with  little  or  no  impairment  of  the  general  health.  Frequency  of 
micturition  and  polyuria  are  generally  the  first  signs,  the  urine  remain- 
ing clear  and  without  chemical  change,  other  than  a  lowered  specific 
gravity.  Later  the  urine  becomes  cloudy  from  the  presence  of  pus. 
This  change  may  occur  gradually,  or  suddenly  from  the  rupture  of  an 
infected  focus  into  the  pelvis.  At  this  time,  the  urine  may  contain  a 
trace  of  albumen,  blood  cells,  pus  cells,  and  caseous  masses.  Lumbar 
pain  or  soreness  may  be  noted,  and  an  evening  rise  of  temperature  is 
the  rule.  Later  the  pain  may  increase  and  in  a  few  instances,  acute 
renal  colic  may  be  observed  from  the  passage  through  the  ureter  of 
blood  clots  or  masses  of  caseous  or  necrotic  tissue.  When  the  bladder 
mucous  membrane  becomes  involved,  the  frequency  is  exaggerated, 
and  pain  and  tenesmus  develop.  Fever  then  becomes  more  constant, 
the  appetite  suffers  and  weakness  and  emaciation  occur.  Occasionally 
blood  may  appear  in  the  urine  in  sufficient  quantity  to  be  detected 
by  the  naked  eye.  Physical  examination  at  any  time  may  reveal  the 
presence  of  a  tender  renal  tumor,  and  in  certain  rare  cases  a  thickened 
ureter  may  be  palpated  in  the  loin  or  as  a  result  of  vaginal  or  rectal 
examination.  Great  frequency  of  micturition,  severe  tenesmus,  and 
the  passage  of  a  few  drops  of  blood  at  the  end  of  each  act,  indicate  that 
the  disease  has  extended  to  the  trigone  or  prostatic  urethra.    These 


620  DISEASES  OF  THE  KIDNEYS  AND   URETERS 

symptoms  with  an  inability  of    the  bladder  to  hold  more  than  an 
ounce  or  two  of  urine  strongly  suggest  an  interstitial  cystitis. 

Diagnosis. — The  symptoms  and  signs  of  renal  tuberculosis  in  the 
early  stage  are  rarely  sufficient  to  enable  one  to  make  a  diagnosis. 
The  occurrence  of  a  cloudiness  of  the  urine  without  history  of  an 
acute  infection,  with  slight  frequency  should  always  awaken  suspicion. 
If  to  this  is  added  an  evening  rise  of  temperature  with  blood  and 
pus  cells  in  the  urine,  and  the  presence  of  a  tender  renal  tumor,  tuber- 
culosis is  probably  present.  One  cannot,  however,  feel  sufficiently 
sure  of  the  diagnosis  to  advise  radical  surgical  treatment,  until  tubercli 
bacilli  have  been  demonstrated  in  the  urine.  This  is  not  always  easy 
even  when  all  symptoms  and  signs  point  to  the  disease,  for  as  accurate 
an  observer  as  Rovsing  reports  that  in  205  of  his  cases  he  has  been 
unable  to  demonstrate  the  presence  of  bacilli  by  the  ordinary  methods. 
A  twenty-four  hour  specimen  of  the  urine  should  be  allowed  to  settle, 
the  sediment  precipitated  by  the  centrifuge  and  at  least  ten  slides 
thoroughly  examined.  A  negative  result  does  not  exclude  tuberculosis, 
as  inoculation  of  a  guinea-pig  often  will  give  a  positive  result  when  the 
microscope  fails. 

Two  important  facts  must  next  be  established,  first  which  kidney 
is  the  seat  of  the  disease,  and  second  what  is  the  functional  ability 
of  the  opposite  organ.  This  is  best  determined  by  cystoscopy,  cathe- 
terization of  the  ureters,  and  careful  chemical  and  microscopic  exami- 
nation of  the  separated  urines.  Intravesical  separators  should  not 
be  employed,  as  an  isolated  patch  of  tuberculosis  inflammation  on  the 
bladder  wall  might  easily  contaminate  the  specimen  drawn  from  the 
side  of  the  healthy  kidney. 

Where  ureteral  catheterization  by  means  of  the  cystoscope  is  im- 
possible, as  in  certain  advanced  cases  of  urethral  obstruction,  vesical 
infiltration  or  ulceration,  several  other  methods  may  be  employed. 
First,  suprapubic  cystotomy  and  direct  catheterization  of  the  ureters 
through  the  cystotomy  wound;  second,  closed  renal  exclusion,  exposing 
the  presumably  diseased  ureter  in  the  loin,  and  affecting  temporary 
closure  of  the  tube  by  digital  pressure,  temporary  ligature  or  soft 
rubber  coated  forceps  as  recommended  by  Mation  and  FedorofT. 
This  allows  the  urine  from  the  presumably  healthy  kidney  only  to  flow 
outward  through  the  natural  passages,  and  be  subjected  to  the  various 
functional  tests;  but  the  method  has  the  objection  that  urine  secreted 
by  a  healthy  kidney  may  become  contaminated  by  passing  through  an 
infected  bladder.  Third,  open  ureteral  exclusion  as  recommended  by 
Rochet  and  Kelly.  This  gives  more  accurate  results,  for  the  ureter  is 
opened  by  a  longitudinal  cut  above  the  closed  segment  and  the  uncon- 
taminated  urine  collected  and  examined. 

Rovsing's  plan  is  to  expose  both  kidneys  and  after  careful  inspection, 
palpation,  and  examination  of  the  upper  part  of  the  ureters,  decide 
on  the  kidney  most  diseased,  the  probable  functional  activity  of  the 
other,  and  the  operative  treatment  to  be  carried  out.       He  reports 


INFLAMMATORY  DISEASES  OF  THE  KIDNEY  621 

30  cases  examined  in  this  manner,  in  24  of  which  nephrectomy  was 
performed,  with  recovery  in  every  instance. 

Prognosis. — This  depends  largely  on  the  stage  of  the  disease,  the 
amount  of  tissue  involved,  and  the  resistance  of  the  individual  patient. 
Undoubtedly  spontaneous  arrest  of  the  disease  takes  place,  and  the 
remaining  cheesy  focus  may  become  inocuous,  encapsulated,  or 
calcified. 

It  is  often  observed  in  surgical  tuberculosis,  if  the  primary  or  chief 
active  focus  of  the  disease  is  removed,  arrest  or  cure  of  the  remaining 
lesions  often  takes  place. 

For  that  reason  one  often  advises  nephrectomy  in  cases  of  advanced 
renal  tuberculosis,  even  when  the  ureter  and  bladder  are  the  seat  of 
definite  lesions.  Early  nephrectomy  may  be  expected  to  cure  from  60 
to  70  per  cent,  of  the  cases  where  the  opposite  kidney  is  free  from  the 
disease. 

Rovsing  in  a  recent  report  states  that  75  per  cent,  of  his  cases  are 
cured,  and  Israel  reports  a  mortality  of  25,  12  per  cent,  immediate 
or  operative,  and  13  per  cent.  late. 

Harris  has  reported  one  cure  and  two  cases  followed  by  marked 
improvement  where  he  removed  a  tuberculous  kidney  in  the  presence 
of  secondary  involvement  of  the  remaining  organ. 

Treatment. — If  in  an  otherwise  healthy  individual,  tuberculous 
disease  can  be  accurately  located  in  one  kidney,  the  indications  are 
for  nephrectomy  at  the  earliest  possible  moment.  Nephrectomy  is  also 
to  be  advised  in  cases  of  early  secondary  involvement  of  the  bladder 
mucous  membrane.  The  presence  of  a  quiescent  tuberculous  focus 
in  the  lung,  epididymis,  or  a  joint,  does  not  contra-indicate  the  opera- 
tion where  the  renal  lesion  is  the  active  one,  giving  rise  to  toxemia 
which  lowers  the  patient's  resistance. 

Nephrectomy  is  occasionally  justifiable  in  cases  of  secondary  in- 
volvement of  the  opposite  kidney,  and  in  the  presence  of  advanced 
lesions  in  other  organs,  for  the  relief  of  suffering. 

In  performing  nephrectomy,  the  author  does  not  advise  prolonged 
or  extensive  operation,  for  the  removal  of  the  entire  ureter  even  if 
largely  involved.  As  much  of  the  ureter  as  can  be  removed  through  a 
generous  incision  should  be  excised,  the  end  ligated,  cauterized,  and 
dropped  back  into  the  retroperitoneal  space.  In  cases  of  grave  sepsis 
from  a  mixed  infection,  resulting  in  pyonephrosis,  nephrotomy  with 
drainage  occasionally  will  be  indicated.  In  these  cases  the  secondary 
nephrectomy  should  be  performed  as  soon  as  the  severe  toxemia  has 
abated,  as  dense  adhesions  rapidlv  form,  rendering  subsequent  removal 
difficult. 

In  inoperable  conditions,  residence  in  a  mountainous  district, 
especially  when  surrounded  by  pines,  is  of  decided  advantage,  the 
painful  symptoms  often  disappearing  in  a  surprisingly  short  period 
of  time.  Tonics,  cod-liver  oil,  tuberculin,  will  be  found  of  benefit 
in  these  unfortunate  cases. 


622  DISEASES  OF   THE  KIDNEYS  AND   URETERS 

RENAL  CALCULUS. 

Under  certain  conditions  of  the  body  metabolism  solid  substances 
which  are  normally  in  a  state  of  solution  in  the  urine  are  precipitated. 
This  precipitation  may  take  place  in  the  kidney  or  bladder,  and 
when  unaccompanied  by  any  other  pathologic  condition  the  minute, 
sand-like  masses  are  washed  away  by  the  urine,  a  condition  usually 
spoken  of  as  gravel.  If  in  addition  to  the  presence  of  the  precipitated 
solid  particles  we  have  a  minute  blood  clot,  bit  of  mucus,  or  some  other 
albuminoid  substance,  the  particles  are  often  glued  together,  forming 
a  small  concrement,  which  may  pass  away  with  the  urine  or  remain 
to  increase  in  size,  giving  rise  to  more  or  less  disturbance  in  the  function 
of  the  organ  by  its  presence  alone  or  by  the  inflammatory  reaction 
which  it  begets. 

Causes. — Gouty  diathesis,  sedentary  habits,  lack  of  exercise,  rich 
food,  alcohol,  inflammatory  conditions  of  the  urinary  organs,  and 
trauma  may  be  enumerated  as  among  the  causes  of  calculus. 

Varieties. — Primary  renal  calculi  may  be  composed  of  uric  acid 
or  the  urates,  calcium  oxalate,  phosphate  of  lime,  carbonate  of  lime, 
cystin,  or  xanthine.  These  may  occur  without  pre-existing  inflamma- 
tion of  the  pelvic  mucous  membrane.  Secondary  calculi  are  composed 
of  ammoniomagnesium  phosphate  alone  or  in  combination  with  other 
salts,  and  are  generally  the  result  of  an  inflammatory  process  in  the 
kidney  or  pelvis.  While  primary  stone  may  arise  at  any  age  the  calculus 
of  infancy  is  generally  composed  of  ammonium  urate,  that  of  early 
adult  life  of  uric  acid  or  the  urates,  that  of  later  life  of  calcium  oxalate. 

Pathology. — One  or  both  kidneys  may  be  affected,  the  number  of 
cases  of  bilateral  stone  encountered  clinically  bring  from  10  to  15 
per  cent.  The  number  of  concretions  in  each  may  vary  from  one  to 
several  hundred.  The  presence  of  a  calculus  in  a  healthy  kidney 
gives  rise  at  first  only  to  a  catarrhal  exudate  made  up  of  mucus  and 
white  cells,  later  the  mucous  membrane  of  the  pelvis  becomes  per- 
manently congested  and  thickened,  and  the  parenchyma  slowly 
develops  changes  which  result  in  chronic  nephritis  and  sclerosis. 
In  the  majority  of  instances  the  stones  lie  free  in  the  pelvic  cavity, 
occasionally  one  will  be  found  impacted  in  one  of  the  calyses,  and, 
rarely,  a  calculus  will  appear  completely  imbedded  in  the  renal  tissue. 
If  at  this  stage  sudden  and  complete  ureteral  obstruction  occurs  from 
impaction  of  the  stone,  or  from  any  other  cause,  the  kidney  becomes 
functionless  and  finally  atrophies.  If  the  obstruction  is  incomplete 
or  intermittent,  hydronephrosis  will  develop.  Sooner  or  later  in  most 
cases  of  renal  calculus  infection  occurs.  In  the  majority  of  instances 
this  reaches  the  damaged  kidney  by  the  blood  route.  If  the  process 
is  a  virulent  one,  the  acute  or  fulminating  type  of  hematogenous  in- 
fection may  result.  If  the  infection  is  milder  in  character,  the  end 
result  may  be  a  pyelitis,  a  pyelonephritis,  renal  abscess,  perinephritic 
abscess  or  if  ureteral  obstruction  be  added,  pyonephrosis.     If  both 


RENAL  CALCULUS  623 

ureters  become  obstructed  as  a  result  of  calculous  disease,  calculus 
anuria  develops,  which,  unless  speedily  relieved  by  surgical  means, 
gives  rise  to  fatal  uremia. 

Symptoms. — That  renal  calculus  may  exist  for  a  long  period  of 
time  without  giving  rise  to  symptoms  referable  to  the  kidney,  is 
abundantly  proved  by  numerous  autopsies.  In  these  instances 
the  stone  usually  occupies  a  position  in  the  parenchyma  of  the  kidney 
or  is  firmly  fixed  in  one  of  the  calices.  Movable  stone  in  the  pelvis 
of  the  kidney  almost  invariably  gives  rise  to  one  or  more  of  the  fol- 
lowing symptoms:  pain,  hematuria,  vesical  irritability,  and  pyuria. 
The  pain  may  be  constant,  located  in  the  flank,  occasionally  radiating 
downward  along  the  course  of  the  ureter;  less  frequently  it  extends 
upward  to  the  shoulder  or  chest,  and  rarely  it  is  referred  entirely  to 
other  organs,  as  the^testicle,  ovary,  opposite  kidney,  or  the  sole  of  the 
foot  (Morris).  In  most  cases,  however,  the  pain  is  paroxysmal  severe 
in  character,  radiating  downward  from  the  flank  along  the  course  of 
the  ureter  to  the  given  testicle  or  urethra.  Retraction  of  the  testicle 
may  occur,  also  a  frequent  desire  to  urinate  with  visical  and  in  children 
rectal  tenesmus.  During  these  attacks  the  suffering  often  is  extreme, 
necessitating  large  doses  of  morphine  or  the  administration  of  an 
anesthetic  for  its  relief.  The  point  of  greatest  intensity  of  the  pain 
may  be  somewhat  below  the  kidney.  Not  infrequently  it  is  located 
at  or  near  McBurney's  point  on  the  right  side  or  at  a  corresponding 
point  on  the  left.  These  attacks  of  renal  colic  are  generally  character- 
ized by  a  sudden  onset  and  by  equally  sudden  relief.  They  are  often, 
but  by  no  means  always,  caused  by  the  passage  of  a  stone  from  the 
kidney  to  the  bladder,  for  in  many  cases  the  stone  is  far  too  large  to 
enter  the  ureter.  In  these  cases  the  pain  is  probably  due  to  the  forcing 
downward  of  the  calculus  against  the  ureteral  orifice,  giving  rise  to  a 
transitory  hydronephrosis.  Next  to  pain,  the  most  characteristic  symp- 
tom of  renal  calculus  is  hematuria.  The  amount  of  blood  lost  is 
exceedingly  variable,  but,  as  a  rule,  it  may  be  said  that  it  is  rather 
more  than  in  renal  tuberculosis,  and  rather  less  than  in  tumor  of 
the  kidney.  The  hemorrhage  is  apt  to  accompany  and  follow  attacks 
of  colic,  and  both  frequently  are  occasioned  by  exercise  or  riding. 
While  noticeable  hematuria  is  often  absent,  the  microscope  is  pretty 
sure  to  reveal  the  presence  of  blood  at  some  period  of  the  disease. 
In  32  cases  of  renal  or  ureteral  stone  recently  reported  by  the  author, 
hematuria  was  present  in  16.  In  only  7  of  these  cases,  however, 
was  it  present  in  sufficient  quantity  to  color  the  urine,  so  that  it  was 
recognized  by  the  patient;  in  9  it  was  found  only  by  the  microscope. 
Vesical  irritability,  evidenced  by  frequent  and  painful  micturition, 
is  occasionally  present,  and  is  often  a  misleading  symptom,  directing 
the  attention  of  the  surgeon  to  the  bladder  or  prostate.  Pyuria  may 
occur  as  a  late  symptom.  The  kidney  origin  of  the  pus  is  indicated 
by  the  acid  reaction  of  the  urine  and  by  the  presence  of  casts  and  renal 
epithelia. 


624  DISEASES  OF   THE  KIDNEYS  AND    URETERS 

Nausea,  vomiting,  prostration,  cold  sweats,  and  extreme  nervous 
irritability  often  accompany  the  attacks  of  colic.  Fever  may  be 
present  after  infection  has  occurred.  When  pyonephrosis  or  peri- 
nephritic  abscess  is  added,  there  also  may  be  chills,  sweats,  and  other 
evidences  of  general   sepsis. 

Of  the  physical  signs  of  renal  calculus,  the  only  one  upon  which 
much  reliance  can  be  placed  is  the  presence  of  a  characteristic  x-ray 
shadow.  In  fact  rontgenology  has  advanced  to  such  an  extent  during 
the  past  half  decade,  that  at  present,  a  negative  as  well  as  positive 
rontgenographic  diagnosis  of  renal  calculus  can  be  made  in   about 


Fig.  291. — Radiogram  of  renal  stone.     (From  plate  by  Dr.  L.  G.  Cole.) 

98  per  cent,  of  the  cases.  Costovertebral  tenderness  to  pressure 
or  percussion  is  frequently  present,  and  is  thought  by  some  authorities 
to  be  almost  pathognomonic,  but  in  the  writer's  opinion  it  is  of  doubtful 
value,  as  it  is  so  often  encountered  in  other  pathological  conditions. 
The  occurrence  of  a  renal  tumor,  while  occasionally  present  in  cal- 
culous disease  due  to  a  plugging  of  the  ureter,  is  also  more  char- 
acteristic of  other  conditions. 

To  be  of  diagnostic  value  an  .r-ray  plate  must  show  the  structure 
of  the  vertebral  bodies,  the  transverse  processes  to  their  tips,  and  the 
outline  of  the  psoas  muscle.  In  addition  to  this  the  shadow  made  by 
the  calculus  should  have  a  distinct  and  well-defined  outline.     Of  the 


RENAL  CALCULUS  625 

various  calculi,  those  showing  the  darkest  shadows  are  the  phosphatic 
and  the  calcium  oxylate  stones,  those  showing  the  faintest  shadows 
are  composed  of  pure  uric  acid.  Mixed  stones  and  those  composed  of 
the  urates  and  of  cystin  give  shadows  which  in  distinctness  vary 
between  the  two  extremes  (Figs.  291  and  292). 

Diagnosis. — A  renal  calculus  may  exist  without  symptoms  or 
signs,  and  as  all  the  symptoms  of  this  disorder  may  occur  in  other 
pathologic  conditions,  an  absolute  diagnosis  without  an  .-r-ray  plate 
is  often  impossible.  The  association,  however,  of  colic,  hematuria, 
and  vesical  irritability,  generally  following  bodily  exercise,  riding  or 


Fig.  292. — Radiogram  of  renal  stones.     (From  plate  by  Dr.  L.  G.  Cole.) 

jolting,  together  with  the  constant  presence  of  tenderness  over  the 
corresponding  kidney,  in  the  absence  of  bladder,  prostate,  or  urethral 
lesion,  renal  tumor,  or  the  evidences  of  tuberculosis,  would  render 
the  diagnosis  of  renal  calculus  highly  probable.  If,  in  addition  to 
this,  the  urine  collected  from  the  affected  side  gave  evidences  of 
pus,  blood,  or  crystals,  while  that  from  the  opposite  kidney  was 
normal,  the  probability  would  be  accentuated.  The  demonstration 
of  a  distinct  shadow  in  an  a>ray  plate  corresponding  to  the  position 
of  the  affected  kidney  would  render  the  diagnosis  practically  certain. 
It  is  rare,  however,  to  encounter  cases  presenting  such  an  association 
of  symptoms.  The  constant  presence  of  one  or  more  of  these  symptoms 
40 


626  DISEASES   OF   THE  KIDXEYS  AXD    URETERS 

or  sign-,  it  of  sufficient  severity  to  interfere  with  the  health  and  comfort 
of  the  individual,  if  not  relieved  by  hygienic  or  medical  means,  would 
justify  an  exploratory  nephrotomy,  even  where  it  was  found  to  be 
impossible  to  obtain  the  confirmatory  evidence  of  an  x-ray  plate, 
and  if  no  stone  was  found,  in  all  probability  some  other  lesion  would 
be  discovered  and  the  patient  relieved. 

Prognosis. — Although  a  stone  in  the  kidney  may  remain  symp- 
tomless for  a  long  period  of  time,  and  apparently  occasion  no  serious 
mischief,  still  in  the  great  majority  of  instances  it  eventually  gives 
rise  to  infection  and  other  lesion  which  lead  to  destruction  of  the 
organ  or  the  life  of  the  individual. 

Treatment. — Prophylactic  treatment  should  be  instituted  in  all 
cases  in  which  a  tendency  to  the  formation  of  stone  is  evidenced 
by  the  passage  of  gravel.  This  should  consist  in  regular  exercise, 
the  avoidance  of  rich  food  and  alcohol,  and  the  daily  ingestion  of 
large  quantities  of  water.  The  alkaline  diuretics  may  be  employed 
if  there  is  constant  hyperacidity  of  the  urine.  The  treatment  of  an 
attack  of  renal  colic  should  consist  in  a  hot  bath,  copious  draughts 
of  water,  morphine  subcutaneously  or  the  inhalation  of  chloroform. 
In  the  presence  of  symptoms  pointing  strongly  to  renal  calculus, 
thf  treatment  should  be  early  exploratory  nephrotomy  or  pyelotomy, 
and  removal  of  the  stone  if  present.  The  operation  is  practically 
without  danger  if  undertaken  at  an  early  period,  before  the  renal 
function  has  been  seriously  compromised  by  infection  or  extensive 
destruction  of  the  secreting  substance.  To  delay  operation  in  the 
hope  of  causing  the  stone  to  disappear  as  a  result  of  treatment  by 
mineral  waters  or  medicine,  is  but  to  invite  disaster  and  to  postpone 
operation  to  a  period  when  the  conditions  are  far  less  favorable,  as 
the  mortality  following  nephrotomy  for  pyonephrosis,  and  nephrec- 
tomy necessitated  by  complete  disorganization  of  the  kidney,  renders 
these  operations  far  more  formidable  procedures. 

The  technic  of  nephrolithotomy,  nephrotomy,  and  nephrectomy  is 
de-cribed  on  page  641. 

Calculus  Anuria. — Complete  anuria  from  calculous  disease  may  occur 
iiuder  the  following  conditions:  first  impacted  calculus  in  both  ureter>: 
second  impacted  calculus  in  one  ureter,  the  other  kidney  being  congeni- 
tally  absent,  previously  removed  or  functionless  from  tuberculosis  or 
some  other  non-calculous disease;  third  calculus  impacted  in  one  ureter, 
the  other  ureter  being  occluded  by  inflammatory  stricture,  tuberculous 
ulceration,  new  growth,  or  a  surgical  ligature. 

Symptoms. — The  symptoms  of  this  condition  are  pain,  the  occurrence 
of  complete  suppression  of  urine,  and  later  the  symptoms  of  progressive 
uremia.  The  pain  usually  is  severe  and  at  first  resembles  the  ordinary 
renal  colic,  later  it  changes  to  a  moderate  constant  aching  pain  in  the 
loin,  which  gradually  disappears  as  the  symptoms  of  uremia  develop. 
While  the  pain  and  costovertebral  tenderness  generally  indicate 
the  side  of  the  recent  obstruction  and  consequently  the  potentially 


TUMORS  OF  THE  KIDNEY  AND  SUPRARENAL  GLAND     627 

active  kidney,  this  should  if  possible  be  confirmed  by  an  .r-ray  plate, 
cystoscopy  and  ureteral  catheterization. 

Prognosis. — The  prognosis- in  calculous  anuria  is  grave;  in  only  about 
20  per  cent,  of  the  cases  has  the  condition  been  relieved  spontaneously. 
If  unrelieved  death  takes  place  in  from  eight  to  twenty  days  in  the  great 
majority  of  cases,  although  111  and  Miningham  have  recently  reported 
a  success  in  which  operation  was  not  performed  until  the  twenty-third 
day. 

Treatment. — The  treatment  should  consist  in  exploratory  nephrotomy 
or  ureterotomy,  with  removal  of  the  obstructing  calculus. 

TUMORS  OF  THE  KIDNEY  AND  SUPRARENAL  GLAND. 

Both  benign  and  malignant  tumors  occur  in  the  kidney.  In  the 
older  text-books,  sarcoma,  carcinoma,  and  adenoma  are  spoken 
of  as  those  most  frequently  observed.  Since  the  classical  article  by 
Grawitz,  published  in  1883,  in  which  he  called  attention  to  the  fre- 
quency of  tumors  arising  from  adrenal  rests,  a  great  deal  of  study  has 
been  given  to  these  neoplasms,  which  has  resulted  in  a  decided  change 
in  nomenclature  and  an  entirely  new  conception  of  the  pathology 
of  renal  growths. 

Regarding  frequency,  Watson  states  that  the  pathologic  records 
of  the  Boston  City  and  Massachusetts  General  Hospitals  for  the 
past  ten  years  show  that  considerably  more  than  50  per  cent,  of  all 
renal  tumors  encountered  could  be  classed  as  hypernephromata. 

Benign  Tumors. — Benign  tumors  of  the  kidney  are  rare.  Papillo- 
mata  occur  in  the  pelvis,  and  grow,  as  a  rule,  slowly.  Like  papillomata 
of  the  bladder,  they  have  a  strong  tendency  to  degenerate  into  epithelio- 
mata.  Adenomata  are  occasionally  encountered  arising  from  the  renal 
parenchyma.  They  are  generally  encapsulated,  but  prone  to  malignant 
change.  Angiomata  may  arise  from  the  papilla?  and  give  rise  to  copious 
hemorrhage.  Lipomata,  fibromata,  myxomata,  and  dermoids  have  been 
observed,  but  are  exceedingly  rare. 

Malignant  Tumors. — Malignant  tumors  of  the  kidney  are  much 
more  frequent  than  the  benign  varieties. 

Hypernephromata. — These  growths  are  of  frequent  occurrence, 
and  arise  from  small  aberrant  masses  of  adrenal  tissues  beneath  the 
capsule  or  imbedded  in  the  substance  of  the  organ.  They  appear 
as  circumscribed  yellow  or  reddish  nodules  beneath  the  kidney  capsule, 
or  as  irregular  nodular  outgrowths  involving  a  part  of  or  the  entire 
kidney.  They  may  grow  slowly,  become  apparently  arrested,  or  at 
any  time  take  on  a  rapid  growth  and  reach  an  enormous  size.  The 
disease  not  infrequently  extends  into  neighboring  veins,  and  may 
give  rise  to  an  irregular  metastasis.  These  metastases  occur  in  any 
organ  or  tissue  of  the  body,  but  appear  more  frequently  in  the  bones 
and  lung.  The  metastatic  deposits  preserve  the  histologic  structure 
of  the  original  growth.     They  rarely  involve  the  lymphatics. 


628  DISEASES  OF   THE  KIDNEYS  AND   URETERS 

The  tumor  may  remain  for  years  as  an  innocent  growth,  but  at 
a  later  period  it  almost  invariably  exhibits  well-marked  evidences 
of  malignancy. 

Like  normal  adrenal  tissue,  these  tumors  have  the  power  of  changing 
the  blue  reaction  of  starch  and  iodine  into  a  pale  pink  color.  A  knowl- 
edge of  this  fact  may  enable  one  to  make  a  rapid  diagnosis  at  operation. 

Sarcomata. — Sarcoma  occurs  most  frequently  in  children  under 
five  and  in  adults  between  twenty  and  fifty.  The  growth,  if  of  the 
small  round-cell  variety,  is  rapid,  and  the  tumor  may  attain  a  large 
size,  sometimes  occupying  one-half  or  more  of  the  abdominal  cavity. 
In  the  less  malignant  forms  the  growth  is  more  fibrous  in  character, 
slower,  and  in  adults  may  not  prove  fatal  for  two  or  three  years. 

Carcinomata. — Carcinoma  of  the  kidney  occurs  in  two  clinical  forms, 
an  infiltrating  growth  of  the  parenchyma  and  an  epithelioma  of  the 
pelvis.  It  occurs,  as  a  rule,  late  in  life,  and  is  rapidly  fatal.  The 
epitheliomatous  type  is  frequently  associated  with  calculus  of  the 
pelvis,  which  in  these  cases  probably  acts  as  an  exciting  cause.  Tumors 
having  all  the  histologic  characters  of  an  innocent  adenoma,  in  the 
kidney  not  infrequently  pursue  a  malignant  course,  rapid  recurrence 
after  removal,  and  the  development  of  metastasis  and  cachexia. 

Symptoms. — The  three  most  important  symptoms  of  renal  new 
growth  are  hematuria,  tumor,  and  pain.  At  a  late  period  in  the 
disease  there  may  be  varicocele  from  pressure  on  the  renal  vein, 
and  in  malignant  cases  cachexia. 

Hematuria. — In  the  majority  of  cases  (50  to  GO  per  cent.)  hematuria 
is  the  first  symptom.  It  is  spontaneous,  may  occur  at  night,  and 
often  is  uninfluenced  by  exercise  or  rest.  It  is  generally  intermittent, 
and  may  be  small  in  amount  or  very  profuse. 

Tumor  is  generally  the  first  symptom  in  children,  and  in  about 
one-fourth  of  the  cases  is  the  first  symptom  in  adults.  The  char- 
acteristics which  distinguish  a  renal  tumor  from  growths  in  other 
organs  are  its  position  in  the  loin  behind  the  colon,  its  characteristic 
shape,  its  rounded  outlines,  the  fact  that  it  obliterates  the  natural 
curve  of  the  loin,  but  does  not  bulge  backward,  that  its  mobility 
is  generally  limited,  and  that  it  is  never  separated  from  the  spine 
by  an  area  of  resonance.  "Renal  tumors  never  invade  the  bony 
pelvis,  rarely  reach  the  median  line,  and  frequently  are  separated 
from  the  hepatic  dulness  by  a  resonant  area"  (Morris). 

Pain. — This  occurs  as  a  primary  symptom  in  about  one-third 
of  the  adult  cases.  It  is  mild  at  first,  located  in  the  loin,  and  may 
radiate  to  the  thorax  or  groin.  It  is  intermittent,  uninfluenced  by 
exercise  or  rest,  and  occasionally  is  severe  and  resembles. the  colic 
of  calculus. 

Examination  of  the  urine  may  be  negative.  Red  blood-cells  are, 
however,  often  found  with  the  microscope  when  the  macroscopic 
appearances  are  negative.  A  marked  diminution  in  the  amount  of 
urea  excreted  is  frequently  observed  as  an  early  symptom  (Rovsing). 


TUMORS  OF  THE  KIDNEY  AND  SUPRARENAL  GLAND     629 

As  the  majority  of  renal  new  growths  are  malignant,  and  as  the 
prognosis  is  extremely  grave  unless  the  tumor  is  removed  at  an  early 
period,  it  is  the  duty  of  the  surgeon  to  investigate  at  once  any  ease 
of  symptomless  hematuria.  Cystoseopic  examination  and  the  collec- 
tion of  the  urine  from  each  kidney  will  determine  the  source  of  the 
hemorrhage.  Rontgenographic  examination  not  infrequently,  will 
reveal  the  size,  shape  and  to  a  certain  extent  the  consistence  of  a 
renal  tumor. 

Cysts  of  the  Kidney. — The  cysts  which  occur  in  the  kidney  are  the 
simple  serous  cysts,  containing  clear  or  slightly  blood-stained  fluid; 
perirenal  cysts,  containing  clear  straw-colored  fluid  and  situated 
near  the  renal  pelvis;  the  echinococcus  cysts,  which  may  reach  an 
enormous  size;  the  dermoid,  and  the  condition  described  as  polycystic 
kidney.    The  first  four  varieties  are  exceedingly  rare. 

Polycystic  Kidney. — Polycystic  kidney  occurs  in  both  children  and 
adults.  In  most  of  the  cases  the  disease  is  congenital  and  bilateral. 
The  entire  kidney  is  often  transformed  into  a  mass  of  cysts  of  vary- 
ing size,  causing  atrophy  of  the  secreting  substance  and  symmetric 
enlargement  of  the  organ. 

As  the  condition  gives  rise  to  no  symptoms  other  than  those  of 
pressure  and  atrophy  of  renal  tissue,  many  of  these  cases  reach 
adult  life,  and  the  disease  not  infrequently  is  discovered  by  accident. 
Sooner  or  later,  however,  as  the  disease  slowly  progresses,  a  point 
is  reached  when  the  active  renal  tissue  is  not  sufficient  for  the  needs 
of  the  economy  and  symptoms  appear.  If  in  these  cases  an  unusual 
demand  is  made  upon  the  kidneys  as  a  result  of  some  metabolic 
disturbance  or  infectious  disease,  an  acute  condition  of  uremia 
results. 

Treatment. — In  the  presence  of  symptoms  pointing  to  renal  new 
growth  an  exploratory  incision  should  be  made  in  the  loin  for  purposes 
of  diagnosis.  If  the  tumor  is  probably  malignant,  nephrectomy  should 
be  performed  if  the  opposite  kidney  is-  known  to  be  functionating 
satisfactorily  and  if  the  growth  has  not  infiltrated  the  surrounding 
tissues.  Non-malignant  solid  tumors  should  be  removed  by  partial 
nephrectomy.  This  method  is  also  applicable  to  echinococcus  and 
other  cysts,  although  they  are  often  cured  by  incision  and  stitching 
the  edges  of  the  cyst  to  the  skin.  A  unilateral  large  polycystic  kidney 
sometimes  gives  rise  to  pain  and  other  symptoms  justifying  its  removal 
if  the  other  kidney  is  healthy. 

Adrenal  Tumors.  —  Hypernephromata  or  sarcomata  may  occur  as 
primary  tumors  of  the  suprarenal  gland.  The  relations  of  these  glands 
to  the  kidneys  are  so  intimate,  however,  that  a  differential  diagnosis 
is  rarely  possible. 

Cysts. — Adrenal  cysts  are  rare,  but  have  a  fairly  characteristic 
symptomatology.  They  may  arise  from  the  degeneration  of  solid 
tumors,  from  the  follicles  of  the  gland,  from  parasitic  disease,  or 
from  hemorrhage.     Virchow  described  a  cystic  condition  which  he 


630  DISEASES  OF   THE  KIDNEYS  AND   URETERS 

regarded  as  similar  to  the  cysts  of  the  thyroid,  and  to  which  he  applied 
the  term  suprarenal  struma. 

Symptoms. — The  symptoms  of  a  suprarenal  cyst  are  at  first  indefinite 
discomfort  and  a  sense  of  fulness  in  the  upper  abdomen.  Later  there 
occurs  a  more  or  less  typical  attack  of  renal  colic,  the  pain  starting 
high  up  under  the  diaphragm  and  radiating  downward  or  toward  the 
umbilicus.  These  attacks  are  often  accompanied  by  vomiting  and 
prostration.  At  a  still  later  period  a  tumor  appears  in  the  renal  region, 
which  has  a  tendency  to  grow  upward  and  cause  pressure  on  the  thoracic 
viscera. 

Treatment. — In  the  treatment  of  solid  malignant  tumors  of  the  supra- 
renal gland,  complete  nephrectomy  is  indicated,  if  the  diagnosis  can 
be  made  sufficiently  early  to  afford  a  chance  of  success.  Cysts  of 
sufficient  size  to  cause  painful  symptoms  should  be  removed  by  means 
of  a  lumbar  incision  when  possible.  If  this  is  impossible,  they  should 
be  permanently  drained  by  stitching  it  to  the  abdominal  wound. 

THE  SURGICAL  TREATMENT  OF  NEPHRITIS. 

The  value  of  decapsulation  of  the  kidney  in  chronic  afebrile  nephritis 
is  still  a  disputed  point.  The  original  favorable  reports  of  Edebohls 
had  the  effect  of  stimulating  many  surgeons  to  give  the  method  a 
fair  trial  in  these  otherwise  hopeless  cases;  and  while  there  are  some 
who  have  become  enthusiastic  advocates  of  the  operation,  and  others 
who  unqualifiedly  condemn  it,  the  majority  of  conservative  surgeons 
who  have  given  the  method  a  fair  trial  agree  that  in  a  large  proportion 
of  well-selected  cases,  considerable  benefit  follows  the  procedure. 
While  the  author  has  never  accomplished  a  positive  cure  by  this 
operation,  he  has  observed  a  number  of  cases  in  which  a  striking  and 
rather  unexpected  improvement  has  resulted.  This  was  particularly 
so  in  the  case  of  a  boy,  aged  eight  years,  who  for  four  months  had 
suffered  from  headache,  edema  of  the  face  and  legs,  and  ascites.  He 
had  been  repeatedly  tapped,  and  the  legs  had  been  incised  for  the 
edema.  The  urine  showed  the  signs  of  a  diffuse  nephritis.  After 
double  decapsulation  all  the  symptoms  improved  rapidly.  The  edema 
disappeared,  the  ascites  diminished,  the  headaches  cleared,  and  his 
general  health  improved.  The  change  was  so  striking,  occurred  so 
promptly  after  the  operation,  and  presented  such  a  marked  contrast 
to  the  progressive  deterioration  of  health  while  under  medical  treat- 
ment, that  it  convinced  me  of  the  value  of  the  operation.  This  patient 
was  still  alive  five  years  after  the  operation,  but  presented  unmistakable 
evidences  of  chronic  nephritis. 

The  Treatment  of  Acute  Nephritis  by  Decapsulation. — For  the 
past  few  years  the  author  has  been  interested  in  a  study  of  acute 
hematogenous  infection  of  the  kidney,  the  unilateral  type  of  which 
was  described  earlier  in  the  chapter.  During  the  progress  of  these 
studies,  which  were  both  clinical  and  experimental,  he  became  con- 


77/ a;  surgical  treatment  of  nephritis  631 

vinced  that  in  a  large  number  of  cases,  the  so-called  acute  nephritis 
which  so  often  follows  the  exanthemata  and  other  septic  processes, 
and  is  characterized  by  total  suppression  or  the  passage  of  a  very  small 
amount  of  smoky  highly  albuminous  urine,  fever,  edema  of  the  face 
and  extremities;  and  which  so  frequently  ends  fatally  in  a  few  days, 
differs  in  no  respect  from  the  acute  unilateral  type,  except  for  the 
fact  that  both  kidneys  are  involved. 

Pernice  and  Scagliosi  have  shown  in  their  experimental  work  that 
almost  every  known  form  of  acute  renal  degeneration  and  inflammation, 
from  a  slight  cloudy  swelling  of  the  epithelium  to  a  complete  destruction 
of  the  organ  bv  multiple  abscesses  and  purulent  inflammation,  can 
be  produced  by  passage  of  the  various  pathogenic  organisms  through 
its  vascular  apparatus.  This  fact  was  also  verified  by  the  author  in 
his  experiments.  In.  a  case  of  postscarlatinal  nephritis,  with  severe 
unilateral  symptoms  and  evidences  of  grave  and  progressive  sepsis, 
but  with  only  a  diminished  output  of  urine,  the  writer  performed  a 
nephrectomy  which  was  followed  by  rapid  recovery.  An  examination 
of  this  specimen  showed  that  it  contained  innumerable  septic  infarcts 
and  differed  in  no  respect  from  the  other  cases  of  acute  unilateral 
sepsis  except  that  the  lesions  were  non-suppurative,  and  that  cultures 
taken  from  a  number  of  the  gross  lesions  could  not  be  made  to  grow 
on  any  of  the  ordinary  media. 

While  many  of  these  cases  of  so-called  acute  Bright's  disease  recover 
spontaneously,  yet  it  is  a  well-recognized  fact  that  in  a  large  number 
of  instances  the  kidneys  are  seriously  and  permanently  damaged  by 
the  attack.  In  the  writer's  opinion  a  large  number  of  individuals 
who  suffer  from  chronic  nephritis  in  early  life  can  trace  the  origin 
of  the  affection  to  some  such  acute  process. 

If  decapsulation  has  often  a  marked  beneficial  effect  in  the  chronic 
terminal  conditions  of  kidney  infection,  it  would  seem  to  the  writer 
probable  that  a  much  more  satisfactory  result  would  follow  if  the 
operation  were  performed  during  the  acute  attack  before  permanent 
lesions  were  produced,  and  while  the  kidney  tissue  was  still  acutely 
hyperemic  and  capable  of  rapid  repair.  That  this  is  a  fact  is  evidenced 
by  a  number  of  instances  recently  reported  where  decapsulation  has 
resulted  in  a  prompt  subsidence  of  symptoms. 

That  the  suspended  function  of  the  kidney  often  can  be  rapidly 
restored  by  this  procedure  is  proved  by  the  following  case: 

A  married  woman  was  admitted  to  the  Roosevelt  Hospital  suffering 
from  right-sided  renal  pain,  some  fever,  and  a  diminished  secretion 
of  urine.  Both  ureters  were  catheterized.  From  the  right  only  a 
few  drops  of  smoky  urine  were  obtained  in  fotty  minutes,  from  the 
left  an  abundant  flow  which  was  normal  in  appearance  and  chemical 
reactions.  Right  kidney  exposed,  and  found  to  be  the  seat  of  numerous 
small  elevated  lesions  (septic  infarcts),  the  fatty  capsule  was  thickened, 
infiltrated,  and  moderately  adherent.  The  fibrous  capsule  was 
stripped  from  the  organ  and  the  wound  closed.     Fourteen  days  later, 


632  DISEASES  OF   THE  KIDNEYS  AND    URETERS 

after  complete  healing  of  the  wound,  the  ureters  were  again  catheter- 
ized.  From  both  there  was  an  abundant  flow,  12  cc.  from  the  right 
and  15  cc.  from  the  left  in  twenty  minutes.  Although  the  urine  from 
the  right  kidney  showed  a  trace  of  albumin,  its  percentage  of  urea  was 
higher  than  that  from  the  left,  showing  that  its  function  had  been 
practically  restored.  From  these  observations  the  writer  feels  that 
the  indications  for  treatment  in  cases  of  acute  bilateral  hematogenous 
nephritis  should  be  the  same  as  in  the  unilateral  type;  and  that  early 
decapsulation  should  be  advised  whenever  medical  measures  fail  to 
bring  relief  and  a  fatal  suppression  is  imminent.  The  operation, 
however,  should  be  performed  in  the  shortest  possible  time,  with  the 
minimum  of  anesthesia  and  exposure  on  the  table.  It  is  advisable  to 
have  both  kidneys  operated  upon  simultaneously  by  two  surgeons. 
Carried  out  in  this  way  the  operation  occasionally  can  be  performed 
in  ten  or  fifteen  minutes. 


INJURIES  AND  DISEASES  OF  THE  URETER. 

Prolapse  of  the  Ureter. — This  may  occur  as  a  congenital  or  acquired 
affection,  and  gives  rise  to  a  globular  or  oval  tumor  in  the  bladder. 
It  is  exceedingly  rare. 

Wounds  of  the  Ureter — The  ureter  is  occasionally  injured  in  severe 
traumata,  especially  in  fractures  of  the  pelvis,  as  a  result  of  gunshot 
or  stab  wounds,  and  in  surgical  operations. 

In  subparietal  injuries  extravasation  of  urine  occurs,  followed, 
as  a  rule,  by  abscess  and  evidences  of  septic  intoxication.  In  open 
wounds  a  urinary  fistula  is  established. 

Symptoms. — In  open  wounds  the  diagnosis  is  easily  established 
by  the  presence  of  urine  or  a  urinous  odor  in  the  dressings;  in  sub- 
parietal  ruptures  the  diagnosis  is  not  so  easily  made.  Localized 
pain,  associated  with  hematuria,  particularly  if  the  latter  is  inter- 
mittent, is  strongly  suggestive  of  a  wound  of  the  ureter.  A  rapidly 
progressive  swelling  and  edema  of  the  peri-ureteral  tissues  in  the 
absence  of  signs  of  hemorrhage  indicates  extravasation  and  renders 
the  diagnosis  practically  certain. 

Treatment. — Longitudinal  wounds  may  be  sutured  or,  if  extra- 
peritoneal, will  heal  spontaneously  if  proper  drainage  is  secured. 
Complete  division  of  the  ureter  is  repaired  best  by  Van  Hook's  method 
of  end-to-side  anastomosis.  If  the  wound  is  too  near  the  bladder  to 
permit  of  this  method,  the  distal  portion  should  be  securely  ligated 
with  silk  and  the  proximal  end  implanted  into  the  bladder. 

If  these  procedures  are  impossible,  implantation  of  the  ureter  into 
the  bowel  has  been  suggested,  but  is  more  dangerous  than  nephrec- 
tomy. Ligation  of  the  proximal  portion  of  the  ureter  and  nephrostomy, 
as  suggested  by  Watson,  is  the  safest  procedure  where  it  is  essential 
to  preserve  the  kidney. 


INJURIES  AND  DISEASES  OF   THE   URETER  633 

Ureteritis.  Idiopathic  ureteritis  has  not  been  observed.  The 
disease  occurs  only  in  connection  with  an  infection  of  the  bladder  or 
kidney,  or  of  both  combined.  This  gives  rise  to  two  forms,  the  septic 
and  the  tuberculous. 

Septic  ureteritis  exists  as  an  acute  or  chronic  process.  In  the 
acute  form,  the  mucous  membrane  is  injected,  edematous,  and  in 
places  eroded.  There  may  or  may  not  be  a  periureteral  edema. 
In  the  chronic  form  the  tube  is  thickened,  and  if  obstruction  exists 
there  is  dilatation  above  the  point  of  stricture;  or  if  urethral  stricture 
or  prostatic  enlargement  give  rise  to  the  obstruction,  the  entire  tube 
may  be  dilated,  thickened,  and  tortuous.  In  the  tuberculous  variety 
the  walls  may  be  irregularly  thickened,  giving  a  beaded  appearance, 
and  the  mucous  membrane  is  studded  with  tubercles  or  the  ulcers 
resulting  from  them.  If  obstruction  exists,  dilatation  is  often 
present. 

Symptoms. — These  differ  in  no  way  from  those  of  the  accompanying 
kidney  or  bladder  lesion.  The  pain  is  often  sharply  localized,  and 
tenderness  may  exist  along  the  course  of  the  ureter,  which  occasionally 
may  be  palpated  in  thin  subjects. 

Treatment. — Direct  application  of  antiseptic  or  astringent  fluids 
to  the  diseased  membrane  in  the  septic  cases  has  been  practised 
with  success  by  means  of  the  ureteral  catheter  or  by  irrigation  from 
above  through  a  nephrotomy  wound.  These  measures,  however, 
are  seldom  necessary,  as  treatment  addressed  to  the  renal  or  bladder 
disease  will  usually  be  quite  sufficient.  The  treatment  of  the  tuber- 
culous variety  should  consist  in  removal  when  nephrectomy  is  prac- 
tised. Complete  ureterectomy,  however,  is  rarely  practicable  at  the 
primary  operation,  owing  to  the  difficulty  in  removal  of  the  pelvic 
portion;  nor  is  this  necessary,  for  experience  has  demonstrated  that  a 
small  segment  of  the  ureter,  even  if  extensively  involved,  seldom 
causes  disturbance  if  the  chief  focus  of  the  disease  is  successfully 
removed. 

Obstruction  of  the  Ureter. — Stricture  of  the  ureter  may  result  from 
the  various  forms  of  ureteritis  or  the  pressure  of  outside  tumors  or 
cicatricial  bands.  It  also  results  from  kinking  of  the  ureter  and  impac- 
tion of  a  calculus.  When  the  ureter  is  suddenly  and  completely 
obstructed,  atrophy  of  the  kidney  results;  when  the  obstruction  is 
partial  with  occasional  periods  of  complete  closure,  nephrectasis  or 
dilatation  of  the  renal  pelvis  occurs.  As  the  dilatation  progresses  the 
cortical  portion  of  the  kidney  is  flattened  and  finally  atrophies,  con- 
verting the  organ  into  a  large  oval  thick-walled  cyst.  If  no  infection 
is  present  and  the  fluid  consists  simply  of  accumulated  urine,  the 
condition  is  called  hydronephrosis;  if  pus  is  present,  pyonephrosis; 
if  the  sac  contains  blood,  which  occasionally  occurs  as  a  result  of 
trauma,  the  term  hemaionephrosis  is  used. 

Symptoms. — Symptoms  of  an  acute  obstruction  of  the  ureter,  as 
from  the  impaction  of  a  calculus,  are  those  of  renal  colic  plus  localized 


634  DISEASES  OF   THE  KIDNEYS  AND    URETERS 

tenderness  at  the  point  of  obstruction.  The  urine  may  be  diminished 
in  quantity  and  contain  blood.  In  the  slowly  developing  form  of 
ureteral  obstruction  the  symptoms  are  those  of  hydronephrosis 
which  will  be  described  below. 

Treatment. — This  should,  if  possible,  be  inaugurated  before  the 
process  has  resulted  in  nephrectasis.  When  the  symptoms  point 
to  an  impacted  calculus,  the  ureter  should  be  exposed  by  a  lumbar 
incision  and  the  obstruction  removed. 

Hydronephrosis. — Hydronephrosis  may  result  from  any  obstruction 
to  the  outflow  of  urine.  If  the  obstruction  is  in  the  ureter  from  the 
various  causes  enumerated  above,  unilateral  hydronephrosis  occurs; 
if  due  to  urethral  stricture,  prostatic  disease,  or  a  tumor  of  the  bladder 
involving  both  ureteral  orifices,  the  hydronephrosis  is  bilateral. 

Symptoms. — In  the  early  stages  the  symptoms  are  those  of  the 
obstructing  lesion;  later,  there  may  be  pain  and  a  sense  of  weight 
in  the  lumbar  region,  and  the  gradual  development  of  a  renal  tumor 
which  may  grow  to  an  enormous  size,  filling  half  the  abdominal  cavity. 
Sudden  cessation  of  all  symptoms,  with  rapid  disappearance  of  the 
tumor  and  marked  polyuria,  may  take  place  (intermittent  hydroneph- 
rosis) when  the  cause  of  the  obstruction  is  of  such  a  nature  that  it 
may  be  relieved  by  the  growth  of  the  renal  tumor,  as  the  twisting 
or  kinking  of  a  ureter  in  cases  of  movable  kidney.  These  cases  of 
intermittent  hydronephrosis  are  not  at  all  infrequent,  often  very 
obscure  in  their  etiology,  and  before  the  days  of  the  z-rays  were  prac- 
tically all  diagnosticated  renal  calculus.  An  important  etiologic 
factor  in  these  cases  has  recently  been  shown  to  be  an  aberrant  arterial 
trunk  to  the  lower  pole  of  the  kidney.  This  not  infrequently  lies  in 
front  of  the  ureter  and  in  close  relation  to  it.  Forward  rotation  of 
the  kidney  or  a  slight  descent  of  the  organ  in  these  cases  gives  rise  to 
angulation  and  obstruction.  In  two  cases  of  intermittent  hydro- 
nephrosis, the  author  found  the  cause  to  be  fixation  and  partial  angula- 
tion of  the  ureter  from  adhesions,  the  result  of  an  infected  neighboring 
lymph  node.  It  will  readily  be  appreciated  that  any  factor  which 
serves  to  fix  or  render  stationary  the  upper  segment  of  the  ureter, 
will  favor  angulation  and  obstruction  in  case  of  descent  or  other 
abnormal  mobility  of  the  kidney. 

One  of  the  most  useful  aids  to  diagnosis  in  these  cases  of  ureteral 
angulation  or  obstruction  is  the  evidence  furnished  by  the  .r-rays 
after  injection  of  the  ureter  and  pelvis  with  a  solution  of  col- 
largol. 

Treatment. — If  possible,  remove  the  cause  of  the  obstruction. 
In  the  event  of  an  aberrant  artery  to  the  lower  pole  being  found, 
this  should  be  double  ligated  and  removed.  If  due  to  movable  kidney, 
this  should  be  firmly  anchored;  if  due  to  an  easily  located  obstruction 
in  the  ureter,  this  should  be  exposed  by  a  lumbar  incision,  and  if  possible 
remedied.  If  the  point  of  obstruction  cannot  be  accurately  located, 
expose  the  kidney,  incise,  evacuate  the  fluid,  and  explore  the  ureter 


INJURIES  AND  DISEASES  OF   THE   URETER  635 

with  a  bougie  from  the  pelvis  to  the  bladder.     If  the  obstruction 

cannot  be  relieved,  or  if  the  kidney  is  atrophied,  perform  nephrectomy. 

Ureteral  Calculus.— While  a  calculus  in  its  descent  from  the  kidney 
may  become  impacted  in  any  part  of  the  ureter,  it  is  most  likely  to  be 
arrested  at  its  upper  extremity,  at  or  just  below  the  pelvic  brim,  in 
the  pelvic  portion  near  the  ischial  spine  or  in  the  intramural  segment. 
Ureteral  calculi  are  generally  oblong  in  shape,  and  rarely  give  rise 
to  total  obstruction.  The  irritation  of  an  arrested  calculus  gives  rise 
often  to  ulceration  or  thickening  of  the  mucous  membrane  and  other 
coats  of  the  ureter,  and  produces  more  or  less  narrowing  of  the  tube, 
which  may  effectively  prevent  its  further  progress  toward  the 
bladder. 

Temporary  obstruction  frequently  results  from  change  in  the 
position  of  the  stone  or  from  edema  of  the  adjacent  mucous  membrane. 
This  gives  rise  to  dilatation  of  the  proximal  portion  of  the  tube  and 
renal  pelvis.  Occasionally  such  an  obstruction  becomes  permanent 
and  a  gradually  increasing  hydronephrosis  results,  which  may  at 
any  time  become  infected  by  the  blood  current  or  by  an  ascending 
process  from  the  bladder  or  prostate. 

Symptoms. — That  an  arrested  ureteral  stone  may  give  rise  to  no 
symptoms  is  evidenced  by  the  fact  that  in  many  instances  in  which 
a  calculus  is  known  to  be  lodged  in  the  ureter,  long  periods  of  immunity 
from  symptoms  occur.  Generally,  however,  stones  in  the  ureter 
give  rise  to  severe  pain,  which  may  be  located  over  the  site  of  the 
lesion  or  wholly  confined  to  the  kidney  region.  In  the  majority  of 
cases  typical  renal  colic  occurs,  the  pain  radiating  downward  from 
the  kidney  along  the  course  of  the  ureter,  and  extending  often  to  the 
glans  penis  or  perineum. 

If  the  stone  is  located  in  the  lower  portion  of  the  tube,  vesical 
irritability  may  he  present.  As  in  renal  calculus,  blood  is  often 
present  in  the  urine,  generally,  however,  in  small  amount,  detected 
only  by  the  microscope. 

Cystoscopy  frequently  reveals  an  edema  and  eversion  of  the  ureteral 
orifice.  The  ureteral  catheter  may  or  may  not  be  arrested  at  the 
seat  of  the  stone. 

The  most  reliable  sign  of  a  ureteral  calculus  is  the  presence  in 
an  .'-ray  plate  of  a  distinct  shadow  over  the  course  of  the  ureter. 
In  about  50  per  cent,  of  the  cases  examined  small  round  faint  shadows 
are  seen  in  radiographs  of  the  adult  pelvis.  They  are  often  multiple, 
and  frequently  lie  somewhat  below  and  to  the  outer  side  of  the  normal 
postion  of  the  ureter.  These  may  be  due  to  phleboliths,  small  areas  of 
calcification  in  the  sacral  ligaments,  or,  as  demonstrated  by  the  writer 
on  one  occasion,  to  a  calcified  appendix  epiploica  of  the  sigmoid.  An 
x-ray  plate  taken  after  the  passage  into  the  ureter  of  a  catheter  bearing 
a  metal  stylet  will  enable  one  to  determine  accurately  the  relation  of 
these  shadows  to  the  ureter.  Fig.  293  shows  a  typical  radiograph 
of  an  ureteral  stone;  Fig.  294,  the  atypical  shadows  just  described. 


636  DISEASES  OF   THE  KIDNEYS  AND   URETERS 

Prognosis. — The  prognosis  of  ureteral  stone  in  general  is  unfavor- 
able, as  the  majority  of  stones  which  have  become  arrested  for  any 
length  of  time  do  not  pass  spontaneously;  and  as  long  as  they  remain 
in  the  ureter  there  is  danger  of  permanent  obstruction  or  of  infection 
of  the  corresponding  kidney.  Occasionally  small  stones  after  remain- 
ing in  the  ureter  for  several  days  or  weeks  will  be  passed  into  the 
bladder.  Cabot  has  reported  a  ca%e  where,  in  his  opinion,  such  a 
result  followed  palpation  of  the  region  of  the  ureter  for  purposes  of 
diagnosis,  and  the  writer  has  observed  a  number  of  cases  where  arrested 
ureteral  calculi  were  demonstrated  by  the  .r-rays  and  were  subsequently 
discharged  through  the  bladder  and  urethra. 


Fig.  293. — Radiogram  of  calculus  in  lower  ureter.     (From  plate  by  Dr.  L.  G.  Cole.) 

Treatment. — This  should  depend  largely  on  the  size  of  the  calculus 
as  revealed  by  the  .r-rays.  Small  calculi  under  half  a  centimeter  in 
diameter  generally  pass  spontaneously  if  the  ureteral  walls  are  normally 
elastic.  If  the  stone  is  slightly  larger,  situated  low  down  in  the  canal, 
and  the  symptoms  are  not  too  urgent,  or  of  long  duration,  a  reasonable 
time  should  be  allowed  for  spontaneous  relief.  During  this  period 
the  passage  of  the  stone  may  be  facilitated  by  the  ingestion  of  large 
quantities  of  water,  the  injection  into  the  ureter  of  bland  oil  or  glycerine, 
or  as  recently  suggested  and  successfully  practised  by  Leo  Buerger, 
the  dilatation  of  the  lower  ureter  by  means  of  his  electric  olive-pointed 


TUMORS  OF  THE  URETER  637 

ureteral  dilators.  The  last  two  methods,  however,  require  special 
technical  skill  in  the  use  of  the  cystoscope  and  intravesical  instru- 
ments. When  it  is  not  possible  to  effect  removal  of  the  stone  by 
these  methods,  direct  operative  attack  is  indicated.  Occasionally 
a  ureteral  calculus  seen  by  the  cystoscope  projecting-  from  the  ureteral 
orifice  can  be  dislodged  by  an  ureteral  catheter.  Stones  arrested  in 
the  intramural  segment  of  the  tube  can  be  best  removed  by  suprapubic 
cystotomy  and  slitting  up  the  ureteral  orifice.  All  stones  situated  in 
the  ureter  above  its  junction  with  the  bladder  should  be  approached 
by  the  lumbar  or  inguinal  extraperitoneal  route.  Experience  has 
demonstrated  that  this  method  is  far  superior  to  any  of  the  older 
procedures. 


Fig.  294. — False  shadows  suggesting  ureteral  calculi.     (From  plate  by  Dr.  L.  G.  Cole.) 

In  difficult  cases  Gibbon  has  advocated  opening  the  peritoneal 
cavity  for  palpation,  both  to  locate  the  stone  and  to  assist  in  its 
removal  by  the  extraperitoneal  route.  The  technic  of  this  operation 
will  be  described  at  the  end  of  the  chapter. 

TUMORS  OF  THE  URETER. 

Primary  new  growths  of  the  ureter  are  rare.  Cysts,  papillomata, 
epitheliomata,  and  sarcomata  have  been  observed.  Secondary 
involvement  of  the  ureter  bv  extension  from  the  kidnev  is  more  com- 


638  DISEASES  OF   THE  KIDNEYS  AND   URETERS 

mon.  It  occasionally  happens  that  a  soft  rapidly  growing  tumor 
of  the  renal  pelvis  will  extend  through  the  ureter  to  the  bladder;  or, 
more  commonly,  in  cases  of  papilloma  of  the  pelvis,  the  disease  may 
extend  downward  forming  multiple  small  growths. 

Symptoms. — The  symptoms  are  pain,  hematuria,  nephrectasis,  and 
the  presence  of  a  tumor  in  the  region  of  the  ureter. 

Prognosis. — The  prognosis  will  depend  on  the  character  of  the  growth 
and  the  extent  of  ureter  involved. 

Treatment. — The  treatment  should  consist  in  removal  of  the  diseased 
portion  of  the  ureter,  and,  if  possible,  anastomosis  of  the  divided  ends. 
Occasionally  complete  nephrectomy  and  ureterectomy  are  indicated. 

OPERATIONS  ON  THE  KIDNEY  AND  URETER. 

Before  deciding  upon  any  serious  kidney  operation  it  is  important 
to  determine,  if  possible,  the  functional  competence  of  the  opposite 
kidney.  This,  for  obvious  reasons,  is  particularly  true  in  a  contem- 
plated nephrectomy;  but  it  is  also  desirable  to  determine  this  point 
in  other  operations  which,  while  they  do  not  remove  the  diseased  organ, 
may  at  least  seriously  interfere  with  its  functional  activity  for  a 
limited  period  of  time.  The  methods  of  determining  this  are  the 
following: 

1.  Separation  of  the  Urines. — Obtain  the  urine  from  each  kidney 
by  means  of  ureteral  catheterization  or  the  use  of  the  Harris  segregator, 
and  subject  each  specimen  to  a  careful  chemical  and  microscopic 
examination. 

2.  Cryoseopy. — Determine  the  freezing-point  of  the  blood  serum, 
which  is  normally  0.5(3°  C.  A  lowering  of  this  point  indicates  greater 
molecular  concentration  of  the  blood,  and  a  consequent  impaired 
functional  activity  of  the  kidney.  A  single  healthy  kidney  will 
serve  to  maintain  the  freezing-point  of  the  blood  serum  at  the  normal 
point. 

3.  The  Phloridzin  Test. — Inject  TV  grain  of  phloridzin  beneath 
the  skin  of  the  patient,  after  complete  evacuation  of  the  bladder 
by  catheter.  Obtain  a  specimen  of  the  urine  one-half  hour  after 
the  injection,  and  another  in  one  hour.  If  the  kidneys  are  healthy, 
the  first  specimen  of  urine  will  contain  from  0.4  to  0.5  per  cent,  of 
sugar,  the  second  slightly  less,  the  average  being  about  0.06  per  cent, 
less  than  the  first.  In  disease  of  the  kidney  the  percentage  of  excreted 
sugar  is  decidedly  less,  generally  about  one-half  the  normal  amount, 
and  there  is  less  difference  between  the  first  and  second  specimens. 
Watson,  who  has  recently  investigated  the  subject,  states  that  in  11 
out  of  70  cases  the  findings  were  not  reliable  as  furnishing  indications 
for  operation. 

4.  The  Phenolsulphonephthalein  Test. — The  patient  is  directed  to 
drink  a  pint  of  pure  water.  The  bladder  is  next  washed  out  and  a 
catheter  left  in  place.     A  hypodermic  injection  of  6  mg.  of  the  drug 


OPERATIONS  ON  THE  KIDNEY  AND   URETER  639 

is  then  given;  and  the  time  of  the  first  appearance  of  the  drug  noted 
by  the  occurrence  of  a  pinkish  tinge  made  by  the  urine  dropping 
from  the  catheter  into  a  test  tube  containing  one  drop  of  a  25  per  cent, 
solution  of  sodium  hydroxid.  The  drug  should  appear  in  the  urine  in 
from  seven  to  ten  minutes,  40  to  60  per  cent,  should  be  excreted  in 
the  first  hour,  and  from  20  to  25  per  cent,  during  the  second  hour. 
The  percentage  of  the  excreted  drug  in  the  one  and  two  hour  specimens 
is  accurately  determined  by  diluting  the  specimen  to  one  litre,  rendering 
it  alkaline  by  the  sodium  hydroxid  solution,  and  comparing  the  color 
with  that  of  a  standard  solution  by  means  of  a  Duboscq  colorimeter. 
In  the  last  two  methods,  separation  of  the  urines  by  ureteral  catheter- 
ization will  enable  the  observer  to  form  a  fairly  reliable  estimate  of  the 
functional  competence  of  each  kidney. 

5.  The  Indigo-carmine  Test.— Inject  20  cc.  of  a  0.4  per  cent,  aqueous 
solution  of  indigo-carmine.  Fifteen  minutes  later  introduce  a  cysto- 
scope  and  observe  the  urine  flowing  from  each  ureter.  If  the  urine 
issuing  from  each  ureter  is  of  a  deep  blue  color,  and  if  the  flow  occurs 
in  strong  jets  at  regular  intervals,  it  is  evident  that  no  obstruction 
exists,  and  it  may  be  assumed  that  the  kidneys  are  reasonably  healthy. 
Absence  of  color  in  the  urine  indicates  grave  secretory  disturbance. 

Of  all  these  methods  the  most  reliable  is  a  chemical  and  microscopic 
examination  of  the  separated  urines  obtained  by  ureteral  catheteriza- 
tion, particularly  the  quantitative  estimation  of  urea.  It  frequently 
happens,  however,  that  ureteral  catheterization  is  not  possible  even 
in  expert  hands.  In  these  cases  careful  cystoscopic  observation  of  the 
results  of  the  indigo-carmine  test  will  afford  fairly  reliable  data.  In 
complicated  cases,  as  pointed  out  by  Edwin  Beer,  a  combination  of 
both  methods  is  of  advantage. 

Cryoscopy  gives  misleading  results  at  times,  for  while  it  will  indicate 
with  positiveness  the  fact  that  there  is  sufficient  normal  secreting 
renal  tissue  somewhere  in  the  body,  it  does  not  indicate  in  which  organ 
this  tissue  is  located,  and  as  Rovsing  has  pointed  out  in  bilateral 
renal  disease,  the  kidney  giving  rise  to  the  most  painful  and  distressing 
symptoms  may  contain  the  greater  amount  of  secreting  tissue.  Beer 
has  also  pointed  out  that  a  functionallly  disturbed  kidney  may  cause  a 
sufficient  molecular  retention  to  lower  the  freezing-point  to  a  .dangerous 
level  (0.60°  C.)  without  there  being  any  organic  disease  which  would 
contra-indicate  operation. 

Too  much  reliance  should  not  be  placed  on  any  of  these  methods  in 
determining  the  advisibility  of  operation  on  a  septic  kidney,  as  impair- 
ment of  function  in  the  presumably  sound  kidney  may  be  temporary 
in  character,  due  to  the  toxemia  induced  by  the  sepsis,  and  may  rapidly 
disappear  after  removal  of  the  septic  focus. 

Exposure  of  the  Kidney. — The  kidney  can  be  exposed  by  several 
incisions. 

The  Posterior  Vertical  Incision  (Edebohls). — The  patient  should 
be  placed  prone  on  the  table,  with  a  folded  pillow  or  cylindric  inflated 


(140 


DISEASES  OF   THE  KIDNEYS  AND    URETERS 


rubber  bag  under  the  abdomen  (Fig.  295).  The  same  position  more 
easily  can  be  secured  by  the  use  of  the  kidney  rack — now  generally 
attached  to  modern  operative  tables.  The  incision  should  be  along  the 
external  border  of  the  erector  spina?  muscle,  dividing  skin,  superficial 
fascia,  latissimus  dorsi,  and  lumbar  aponeurosis.  The  retroperitoneal 
space  is  opened  and  the  kidney  exposed  by  tearing  apart  the  perirenal 
fat,  which  will  be  found  in  two  layers  separated  by  the  thin  perinephric 
fascia.  The  last  dorsal  and  iliohypogastric  nerves  will  be  exposed. 
The  kidney  generally  can  be  brought  out  through  this  incision  and 
thoroughly  examined. 

The  Oblique  Lumbar  Incision. — The  patient  should  be  placed  in 
Sim's  position,  with  a  large  pad  under  the  healthy  loin.  The  incision 
should  begin  over  the  junction  of  the  sacrolumbalis  muscle  with  the 
last  rib,  and  extend  obliquely  to  or  near  the  anterior  spine  of  the 
ilium.     The  skin  and  fat  are  divided,  the  latissimus  dorsi  and  external 


Fig.  295. — Edebohls'  kidney  air-cushion,  with  patient  in  position  for  operation. 

oblique  separated  or  divided,  the  lumbar  aponeurosis  incised,  and  the 
perirenal  fat  exposed.  If  more  room  is  needed,  the  incision  may  be 
extended  from  below  forward  and  upward  toward  the  umbilicus 
(Konig),  or  downward  parallel  to  Poupart's  ligament,  separating  the 
fibres  of  the  external  oblique  and  dividing  those  of  the  internal  and 
transversalis.  By  these  incisions  the  entire  retroperitoneal  space  can 
be  exposed  from  the  under  surface  of  the  liver  to  the  pelvis.  The 
former  method  is  useful  in  large  tumors  of  the  kidney;  the  latter,  in 
operations  upon  the  ureter. 

Nephrolithotomy. — Nephrolithotomy  is  an  incision  into  the  kidney 
for  the  removal  of  a  calculus.  The  kidney  may  be  exposed  by  either 
of  the  above-mentioned  incisions,  the  organ  and  pelvis  palpated  for 
evidences  of  stone,  or  needled,  preferably  with  a  blunt-pointed  steel 
knitting-needle.  If  a  calculus  is  detected,  an  incision  should  be  made 
upon'it  through  the  convex  border.  After  removal  of  the  stone  the 
pelvis  should  be  thoroughly  explored  with  the  finger  and  the  patency 


OPERATIONS  ON  THE  KIDNEY  AND   URETER  641 

of  the  ureter  established  by  the  passage  of  a  bougie.  If  no  stone  is 
detected  by  palpation  or  needling,  the  pelvis  may  be  opened  through 
the  cortex  and  its  cavity  explored.  It  not  infrequently  happens  that 
incision  through  an  hyperemic  cortex  gives  rise  to  troublesome  hemor- 
rhage. To  avoid  this  the  writer  has  been  in  the  habit  of  opening  the 
pelvis  in  the  following  manner:  The  thumb  and  forefinger  are  placed 
on  either  side  of  the  pelvis;  a  grooved  director  is  next  passed  through 
the  cortex  into  the  pelvis,  a  closed  pair  of  dressing  forceps  passed 
along  the  groove  in  the  director  into  the  pelvic  cavity  and  withdrawn 
partly  open.     By  this  method  none  of  the  larger  vessels  are  divided. 

Pyelotomy. — With  a  view  to  avoiding  the  often  troublesome  hemor- 
rhage in  making  an  incision  through  the  vascular  renal  cortex,  the 
cavity  of  the  pelvis  may  be  opened  by  a  direct  incision  through  its 
wall,  avoiding  thereby  all  injury  to  the  kidney  parenchyma.  The 
kidney  is  exposed  preferably  by  the  posterior  incision,  the  organ 
delivered  and  the  posterior  wall  of  the  pelvis  freed  from  fat.  The 
entire  sinus  generally  can  be  palpated  by  the  finger,  invaginating  the 
pelvic  wall.  If  a  small  or  moderate  sized  calculus  is  detected,  the 
pelvis  is  opened  by  a  longitudinal  or  transverse  incision,  and  the  stone 
extracted;  after  which  the  opening  into  the  pelvis  is  closed  by  plain 
catgut  sutures  and  a  layer  of  perirenal  fat  stitched  to  the  line  of 
incision.  This  operation,  in  the  author's  opinion,  is  to  be  preferred  to 
cortical  nephrotomy  in  stones  of  moderate  size,  where  the  pelvis  can 
be  readily  exposed. 

Nephrotomy. — Nephrotomy  is  an  incision  into  the  kidney  for  the 
evacuation  of  an  abscess  or  the  relief  of  nephrectasis.  In  opening  the 
pelvis  of  the  kidney  through  its  convex  border  it  is  desirable  to  make 
the  incision  in  the  manner  just  described. 

In  certain  rare  instances  it  is  desirable  to  open  the  pelvis  widely 
or  expose  the  entire  interior  of  the  kidney  parenchyma  by  a  longitu- 
dinal incision.  If  the  incision  is  made  with  the  blade  of  a  knife,  from 
without  inwards,  the  danger  of  a  fatal  hemorrhage  is  considerable. 
Cullen  has  recently  shown  that  incision  from  within  outwards  by  means 
of  a  silver  wire  carried  longitudinally  through  the  organ  on  a  straight 
or  curved  blunt  pointed  liver  needle,  will  greatly  reduce  the  amount 
of  hemorrhage,  provided  the  section  is  made  at  or  near  Brodel's  area 
of  lessened  vascularity.  This  in  the  majority  of  kidneys  lies  about 
half  an  inch  posterior  to  the  midline  of  the  cortical  border.  Often 
it  can  be  determined  by  the  shape  of  the  kidney  whether  this  avascular 
line  lies  normally  behind,  or  in  front  of  the  cortical  border.  In  normal 
cases  (75  per  cent.),  the  anterior  surface  of  the  kidney  is  rounded,  the 
posterior  surface  flat.  In  these  cases  the  posterior  lip  of  the  sinus  is 
notched  and  the  pulsating  arteries  can  be  felt  at  the  anterior  border 
of  the  hilum.  In  25  per  cent,  of  the  cases,  however,  the  anterior 
surface  is  flat  and  notched  while  the  posterior  surface  is  rounded. 
In  these  cases  the  posterior  half  has  the  greater  blood  supply  and  the 
anemic  line  is  just  anterior  to  the  cortical  border. 
41 


642  DISEASES  OF   THE  KIDNEYS  AND   URETERS 

Nephrectomy. — Nephrectomy  may  be  accomplished  through  a  lum- 
bar incision,  or  by  means  of  the  transperitoneal  route.  The  former 
method  is  generally  to  be  preferred.  The  kidney  is  exposed  best  by 
the  oblique  lumbar  or  Konig  incision,  the  pedicle  isolated,  the  vessels 
ligated  separately  or  in  two  masses  by  means  of  strong  ohromicized 
catgut,  and  divided.  The  ureter  is  ligated  separately,  and  after 
division  touched  with  pure  carbolic  acid  or  the  actual  cautery.  In 
tuberculous  or  septic  disease  of  the  ureter  it  should  be  freely  exposed 
and  as  much  removed  as  possible.  The  wound  should  be  closed  by 
layer  suture  with  drainage.  If  the  abdominal  route  is  to  be  employed, 
a  long  vertical  incision  is  made  near  the  outer  border  of  the  rectus 
muscle  separating  its  fibres.  After  opening  the  peritoneal  cavity  the 
parietal  peritoneum  is  divided  along  the  outer  border  of  the  colon,  and 
the  gut  pushed  well  toward  the  median  line,  exposing  the  kidney 
and  its  pedicle.  After  abdominal  nephrectomy  drainage  should  be 
established  through  an  incision  in  the  loin. 


Fig.  296. — Showing  two  of  the  four  suspension  sutures  passed  through  reflected 
and  attached  layers  of  capsule  proper,  without  penetration  of  kidney  substance.  The 
two  companion  sutures,  passed  on  the  opposite  face  of  the  kidney,  are  not  shown. 

Nephropexy. — Nephropexy  is  practised  for  the  purpose  of  anchoring 
a  movable  kidney.  This  is  accomplished  best  by  means  of  the  method 
of  Edebohls  through  the  posterior  vertical  incision.  After  the  organ 
is  exposed,  its  fatty  capsule  should  be  dissected  away  and  the  fibrous 
capsule  stripped  backward  from  an  incision  along  the  convexity. 
The  quadratus  lumborum  fibres  are  exposed  by  a  division  of  its  sheath. 
Four  ehromicized  catgut  sutures  are  then  passed  longitudinally 
through  the  folded  capsule,  two  on  each  side.  Both  ends  of  each 
suture  are  next  passed  outward  through  the  muscle  and  divided 
lumbar  aponeurosis,  those  from  the  posterior  portion  of  the  renal 
capsule  emerging  through  the  posterior  lip  of  the  incision,  those 
from  the  anterior  layer  through  the  anterior  lip.  On  drawing  these 
four  sutures  tight,  the  denuded  convex  border  of  the  kidney  is  brought 
in  contact  with  the  edges  of  the  wound  and  the  exposed  fibres  of  the 
quadratus  muscle.  The  muscular  and  aponeurotic  layer  is  next  closed 
by  interrupted  sutures,  after  which  the  fixation  sutures  are  tied  parallel 


OPERATIONS  ON   THE  KIDNEY   AND   CltETER 


(143 


with  the  wound.  The  skin  should  then  lie  sutured  with  silk  or  silk- 
worm gut.  The  patient  should  he  kept  in  bed  three  weeks  (Figs. 
•>\H\,  297,  2<)v>. 


Fig.  297. — The  kidney  has  been  replaced  and  the  ends  of  the  suspension  sutures 
have  been  brought  through  the  abdominal  wall,  emerging  on  the  outer  surface  of  the 
latissimus  dorsi.  The  fibres  of  the  muscle  have  been  separated  from  each  other,  not  cut, 
in  making  the  incision. 


Pig.  298. — Suspension  sutures  and  sutures  closing  deep  parts  of  wound  tied. 


Ureterotomy  and  Ureterectomy. — Ureterotomy  is  indicated  for  the 
removal  of  a  calculus;  ureterectomy,  for  tuberculosis  or  new  growth. 


644 


DISEASES  OF  THE  KIDNEYS  AND   URETERS 


The  ureter  in  its  upper  portion  may  be  exposed  by  the  oblique  lumbar 
incision.  The  middle  portion  of  the  ureter  may  be  exposed  by  an 
extension  downward  of  the  oblique  lumbar  incision  to  the  iliac  region, 
and  retracting  the  peritoneum  well  toward  the  midline,  exposing  the 
psoas  muscle.  To  expose  the  lower  or  pelvic  portion  of  the  ureter 
several  methods  have  been  suggested.  The  simplest  and  safest 
is  the  iliac  extraperitoneal  route.  An  incision  is  made  parallel  with 
Poupart's  ligament  from  a  point  two  inches  above  the  anterior  superior 
spine  of  the  ilium  to  a  point  about  one  inch  above  the  external  abdomi- 
nal ring.  This  divides  the  skin  and  superficial  fascia.  The  aponeuro- 
sis ofjthe  external  oblique  is  split,  and  the  internal  oblique  and  trans- 


Fig.  299.- 


-Uretro-ureteral  anastomosis,  end-in-side  implantation  (Van  Hook's  method: 
a,  first  step;  b,  second  step;  c,  completed  operation.     (Bryant.) 


versalis  divided  transversely,  exposing  the  subperitoneal  fat.  The 
peritoneum  is  next  separated  from  the  iliac  muscle  and  side  wall  of 
the  pelvis  toward  the  midline  and  held  by  broad  retractors.  The 
ureter  generally  will  be  found  attached  to  the  retracted  peritoneum, 
and  can  be  easily  separated  and  palpated  to  its  entrance  into  the 
bladder.  In  ureteral  calculus  it  is  desirable,  if  possible,  to  push  the 
stone  upward  and  remove  it  through  a  longitudinal  incision  in  the 
healthy  ureteral  wall.  Such  a  wound  in  the  ureter  may  be  united 
with  fine  silk  or  catgut  sutures.  In  the  lumbar  region  the  ureteral 
wound  may  be  left  unsutured  if  adequate  drainage  is  provided. 

For  the  removal  of  the  entire  ureter  in  the  female,  Kelly  advises 
the  combined  lumbar  and  vaginal  method. 


OPERATIONS  OX   THE  KIDNEY  AND   URETER  645 

Uretero-ureterostomy. —  Uretero-ureterostom}-  is  an  operation  for 
divided  ureter.  Carrel  in  his  experimental  work  has  employed  end- 
to-end  suture  of  the  divided  ureter,  using  fine  silk  and  the  technic 
described  for  arterial  or  venous  anastamosis.  He  finds  the  method 
satisfactory  where  the  ureter  is  fairly  large,  but  in  smaller  animals 
stricture  has  almost  invariably  followed.  To  one  unaccustomed 
to  such  work,  the  method  of  Van  Hook  would  be  simpler  and  perhaps 
less  likely  to  be  followed  by  stricture.  Ligate  the  lower  segment  of  the 
ureter  with  strong  silk,  make  a  longitudinal  incision  into  the  tube 
just  beyond  the  ligature,  and  draw  the  upper  segment  through  this 
opening  by  means  of  a  loop  of  catgut  passed  through  the  tip  of  the 
upper  end,  and  then  inward  through  the  incision  and  outward  through 
the  healthy  ureteral  walls  beyond  the  incision.  This  is  tied,  and  one 
or  two  other  sutures'  inserted  about  the  line  of  junction,  or  the  union 
protected  by  means  of  a  fold  of  peritoneum  (Fig.  299).  If  there  is 
considerable  loss  of  ureteral  tissue  and  the  ends  cannot  be  approxi- 
mated, the  kidney  may  be  loosened  from  its  attachments  and  brought 
downward  in  the  loin  until  the  ends  meet  (Bovee) . 

Implantation  of  the  Ureter  into  the  Bladder. — Implantation  of  the 
ureter  into  the  bladder  must  be  undertaken  if  the  distal  end  is  too  short 
to  admit  of  anastomosis.  Ligate  the  distal  end  and  make  an  incision 
into  the  bladder  near  the  ureteral  orifice,  draw  the  upper  segment  of 
the  tube  into  the  bladder  by  means  of  a  loop  of  catgut  as  in  Van  Hook's 
method  of  anastomosis,  introduce  a  few  interrupted  sutures  at  the 
line  of  union,  and  protect  with  a  fold  of  peritoneum  or  omentum. 


CHAPTER  XXIII. 

INJURIES  AND  DISEASES  OF  THE  BLADDER  AND 

URETHRA. 

CONGENITAL  MALFORMATIONS  OF  THE  BLADDER. 

Exstrophy. — This  is  a  failure  of  union  of  the  two  lateral  halves  of 
the  anterior  wall  of  the  bladder  and  the  overlying  soft  parts,  which 
results  in  exposure  of  the  posterior  wall  of  the  bladder  with  its  ureteral 
openings  just  above  the  pubes.  The  condition  has  been  attributed 
to  an  early  arrest  of  development  or  to  an  intra-uterine  rupture  of  the 


// 


Fig.  300. — Exstrophy  of  the  bladder  combined  with  epispadias:  B,  posterior  wall  of  the 
bladder;  U,  U,  orifices  of  the  ureters;  H,  H,  inguinal  hernia  on  each  side.     (Tillmanns.) 

bladder  wall.  The  malformation  is  apt  to  be  associated  with  a  failure 
of  union  of  the  pubic  arch,  and  a  condition  of  complete  epispadias 
in  the  male  and  a  bifid  clitoris  in  the  female  (Fig.  300).  In  the  milder 
forms  of  the  deformity  the  genitals  may  be  normal,  and  only  a  fissure 
in  the  anterior  wall  of  the  bladder  may  be  present.  Occasionally 
the  fissure  is  limited  to  the  abdominal  wall,  through  which  a  perfectly 
closed  bladder  may  protrude.  In  its  worst  form  the  malformation 
is  a  distressing  one,  rarely  capable  of  correction.  The  urine  flows  over 
the  abdomen  and  thighs,  excoriating  the  skin  and  keeping  the  patient 
and  his  clothing  constantly  wet  and  offensive.  The  exposed  mucous 
surface  becomes  inflamed,  sensitive,  and  easily  bleeds. 


INJURIES  OF  THE  BLADDER  G47 

Treatment. — The  treatment  of  this  condition  consists  in  three 
methods:  first,  cleanliness  and  the  use  of  some  closely  fitting  rubber 
receptacle  to  collect  the  urine  and  avoid  soiling  the  clothing;  second, 
an  attempt  to  repair  or  reconstruct  the  anterior  bladder  wall  by 
plastic  operation;  and  third,  to  divert  the  course  of  the  urine  elsewhere, 
remove  the  mucous  membrane,  and  promote  cicatrization  by  skin- 
grafting.  In  case  of  simple  fissure,  closure  often  may  be  accomplished 
by  freshening  the  edges  of  the  cleft,  and  subsequent  layer  suture  as 
in  other  bladder  fistula?.  In  more  aggravated  cases  extensive  plastic- 
operations  are  necessary  to  construct  an  anterior  wall  to  the  bladder. 
For  this  purpose  flaps  are  taken  from  the  abdominal  wall,  thighs, 
prepuce,  or  scrotum,  turned  inward,  so  that  the  cutaneous  surface 
will  be  united  with  the  mucous  membrane  and  form  the  inner  lining 
of  the  newly  constructed  reservoir.  The  rawT  surface  of  this  flap  is 
then  to  be  covered  by  additional  flaps  or  skin-grafts.  The  results  are 
rarely  satisfactory.  If  the  ureters  are  to  be  implanted  into  the  rectum 
or  sigmoid,  the  abdomen  is  opened  above  the  bladder  in  the  median  line, 
the  two  ureters  ligated  near  the  bladder  wall,  their  proximal  portions 
dissected  free  and  implanted  into  an  adjacent  loop  of  the  sigmoid  by 
the  method  of  Van  Hook,  described  above.  Numerous  other  methods 
have  been  proposed,  including  that  by  Trendelenburg,  who  suggested 
division  of  the  sacroiliac  joints  and  crowding  the  pelvic  halves  together, 
thereby  converting  the  exposed  mucous  surface  into  a  longitudinal  sul- 
cus, which  later  could  be  easily  closed.  While  some  measure  of  success 
has  occasionally  followed  all  of  these  methods,  the  condition  of  these 
unfortunate  patients,  at  best,  is  deplorable.  The  author  is  inclined 
to  believe  that  the  most  rational  plan  to  follow  in  the  graver  cases  is 
that  suggested  by  Watson,  to  perform  double  lumbar  nephrostomy, 
ligate,  and  divide  the  ureters,  and  close  the  abdominal  defect  by 
removal  of  the  mucous  membrane,  this  to  be  followed  by  skin-grafting 
or  a  plastic  operation. 

Other  congenital  malformations  are:  double  bladder,  by  a  vertical 
septum  or  transverse  constriction:  diverticula  of  the  mucous  membrane 
alone  or  with  the  muscular  wall;  and  a  patent  urachus  through  which 
urine  may  be  discharged  at  the  umbilicus. 


INJURIES  OF  THE  BLADDER. 

Contusion.— Contusion  of  the  bladder  may  occur  from  any  injury 
which  results  in  a  contusion  of  the  lower  abdomen  or  fracture  of  the 
pelvis.  It  also  may  occur  as  a  result  of  the  careless  use  of  sounds, 
catheters,  or  other  instruments.  The  symptoms  of  a  contusion  of 
the  bladder  may  be  hematuria  and  temporary  vesical  irritability. 
As  a  rule,  no  treatment  is  required  other  than  rest. 

Penetrating  Wounds. — Penetrating  wounds  of  the  bladder  may 
result  from  gunshot  or  stab  injuries  through  the  lower  portion  of  the 


648  DISEASES  OF   THE  BLADDER  AND   URETHRA 

abdominal  wall,  from  wounds  through  the  tissues  of  the  perineum, 
from  the  unskilful  use  of  urethral  or  bladder  instruments,  or  from 
accidental  incisions  during  the  performance  of  surgical  operations  on 
neighboring  structures.  As  the  symptoms  and  treatment  of  these 
rare  injuries  are  similar  to  those  of  the  more  commonly  observed 
ruptures  of  the  bladder,  they  will  be  considered  in  connection  with 
the  latter  in  the  following  section. 

Rupture  of  the  Bladder. — This  injury  may  result  from  a  blow  on  the 
lower  abdomen  when  the  bladder  is  full,  from  fracture  of  the  pelvis 
with  or  without  penetration  of  a  spicula  of  the  broken  bone,  or  from 
simple  overdistension  from  some  pathologic  condition  producing 
complete  obstruction  of  the  urethral  canal,  especially  if  there  is  present 
in  the  bladder  wall  malignant  ulceration  or  a  thin-walled  saccular 
diverticulum.  Ruptures  of  the  bladder  are  divided  into  two  general 
classes,  the  intraperitoneal  and  the  extraperitoneal  ruptures.  In  the 
former  the  rent  occurs  through  the  posterior  or  posterolateral  wall, 
and  the  extravasated  urine  passes  into  the  peritoneal  cavity;  in  the 
latter  the  injury  occurs  in  the  extraperitoneal  portion  of  the  viscus 
and  the  extravasated  urine  collects  in  the  prevesical  space.  Occasion- 
ally ruptures  of  the  bladder  involve  both  the  intraperitoneal  and 
extraperitoneal  portions  of  the  vesical  wall.  Intraperitoneal  ruptures 
are  the  graver  injuries  on  account  of  the  probable  infection  of  the  peri- 
toneal cavity.  In  ruptures  accompanied  by  fractures  of  the  pelvis 
there  is,  in  addition,  frequently  a  rupture  of  the  iliac  vessels,  with 
severe  hemorrhage  and  the  formation  of  large  retroperitoneal 
hematomata. 

Symptoms. — If  the  rupture  is  an  extensive  one,  there  are  symptoms 
of  severe  shock:  pallor,  weakness,  a  rapid,  feeble  pulse,  cold  extremities, 
nausea,  vomiting,  giddiness,  and  cold  perspiration.  In  addition 
there  are  severe  paroxysmal  attacks  of  pain  in  the  lower  abdomen  and 
an  urgent  desire  to  pass  urine.  Efforts  to  empty  the  bladder  result 
only  in  the  passage  of  a  few  drops  of  bloody  fluid  which  does  not 
materially  relieve  the  tenesmus,  and  the  introduction  of  a  catheter 
demonstrates  an  empty  bladder.  If  the  rupture  is  intraperitoneal, 
free  fluid  occasionally  may  be  detected  in  the  peritoneal  cavity  and 
the  symptoms  of  general  peritonitis  soon  appear;  if  extraperitoneal, 
the  extravasated  urine  collects  in  the  space  of  Retzius,  and  appears 
as  an  indurated  swelling  which  sometimes  may  be  appreciated  by 
rectal  as  well  as  abdominal  palpation.  The  induration  also  may 
make  its  appearance  in  the  buttocks  or  spread  through  the  inguinal 
canal  into  the  scrotum. 

The  introduction  of  a  given  quantity  of  boric  acid  solution  through 
a  catheter  into  the  bladder  and  noting  the  amount  returned,  will 
often  serve  as  a  valuable  indication  both  of  the  presence  of  rupture 
and,  to  a  certain  extent,  of  the  size  of  the  rent.  In  untreated  cases 
death  generally  results  from  peritonitis,  uremia,  or  extensive  suppura- 
tion and  sepsis. 


INJURIES  OF  THE  BLADDER  649 

Treatment. — In  the  presence  of  symptoms  suggesting  a  rupture  of 
the  badder,  the  first  indications  are  to  ascertain  if  the  injury  involves 
the  peritoneal  portion  of  the  organ;  and  if  not,  to  locate  accurately 
the  extravasation  and  hematoma.  These  are  best  met  by  a  median 
exploratory  laparotomy.  The  incision  should  be  made  between 
the  umbilicus  and  pubes,  and  when  the  peritoneal  cavity  is  opened 
the  presence  or  absence  of  blood  or  extra vasated  urine  is  demonstrated. 
If  the  rupture  is  intraperitoneal,  the  incision  should  be  enlarged,  the 
rent  in  the  bladder  wall  united  with  two  rows  of  sutures,  the  first  of 
catgut  uniting  the  muscular  coat,  the  second  of  silk  infolding  the 
peritoneum  with  Lembert  or  Halsted  stitches.  The  entire  cavity  of 
the  peritoneum  should  then  be  flushed  wTith  sterile  salt  solution  and 
the  abdominal  wound  closed  with  a  small  cigarette  drain.  A  catheter 
may  be  left  for  a  few  days  in  the  urethra  to  prevent  any  distension  of 
the  bladder  and  strain  upon  the  suture  line. 

If  the  rupture  is  found  to  be  extraperitoneal,  the  abdominal  wound 
should  be  tightly  closed  and  an  incision  made  over  the  prevesical 
space.  This  should  be  freely  exposed,  if  necessary,  by  a  transverse 
partial  division  of  the  attachment  of  the  rectus  muscles.  The  tear 
in  the  bladder-wall  should  be  united  by  two  or  three  layers  of  sutures, 
the  most  external  of  which  should  be  of  chromic  gut  or  silk;  the  extra  v- 
asated  urine  and  blood  should  be  thoroughly  removed,  any  bleeding 
points  secured  by  ligature  or  gauze  packing,  and  perineal  drainage 
established. 

It  frequently  happens  that  rupture  is  produced  by  the  penetration 
of  a  fractured  fragment  of  the  horizontal  ramus  of  the  pubes,  and 
the  resulting  wound  is  large,  ragged,  severely  contused,  and  situated 
low  down,  just  above  the  prostate.  Under  these  conditions  accurate 
suture  is  difficult,  if  not  impossible,  and  it  is  better  to  unite  the  wound 
partly  and  establish  suprapubic  drainage.  Generous  drainage  of  the 
prevesical  space  should  be  employed  in  all  cases  of  extraperitoneal 
rupture,  as  infection  is  almost  always  present,  and  not  infrequently 
considerable  sloughing  of  the  bladder  wall  occurs,  leaving  a  large  rent 
which  heals  very  slowly.  In  these  cases,  as  in  all  cases  of  suprapubic 
drainage,  the  employment  of  intermittent  siphon  drainage  is  of  great 
value,  not  only  in  contributing  to  the  comfort  of  the  patient,  but  by 
prompt  removal  of  all  infected  fluids. 

It  occasionally  happens  in  fractures  of  the  pelvis  that  the  triangular 
ligaments  are  extensively  torn.  This  often  will  give  rise,  through 
cicatricial  contraction,  to  obstinate  urethral  obstruction,  which  develops 
late,  after  perineal  drainage  has  been  abandoned,  and  not  infrequently 
prevents  closure  of  the  suprapubic  fistula.  This  complication  should 
be  met  by  the  use  of  sounds,  and  if  necessary  by  external  urethrotomy. 

Long-continued  perineal  drainage,  or  the  presence  of  an  extensive 
suprapubic  opening,  will  result  in  a  contraction  of  the  bladder,  which 
may  become  so  reduced  in  size  as  to  hold  only  a  few  drachms  of  fluid. 
This  condition  should  be  overcome  by  systematic  daily  stretching 


650  DISEASES  OF   THE  BLADDER  AND   URETHRA 

of  the  bladder  by  the  introduction  of  fluid  through  the  urethra,  the 
suprapubic  opening  being  closed  if  possible  by  digital  pressure.  The 
procedure  is  often  a  difficult  one,  but  is  most  important  for  the  future 
comfort  of  the  patient. 

Foreign  Bodies  in  the  Bladder. — The  introduction  of  foreign  bodies 
through  the  urethra  is  of  fairly  frequent  occurrence,  especially  in 
females.  Hair-pins,  pencils,  bits  of  wax  or  gum,  and  many  other 
substances  have  been  found  by  surgeons.  In  those  who  habitually 
use  the  catheter  it  sometimes  happens  that  an  old  or  brittle  instrument 
will  break  during  its  introduction  or  withdrawal,  leaving  one  or  more 
inches  in  the  bladder.  These  foreign  bodies  give  rise  to  cystitis, 
and  may  cause  ulceration  and  perforation  of  the  bladder  wall;  event- 
ually they  become  encrusted  with  phosphatic  salts,  and  cause  symptoms 
identical  with  those  of  vesical  calculus.  Any  non-absorbable  suture 
material,  especially  silk,  may  act  as  an  irritant  and  become  encrusted 
with  lime  salts,  forming  the  starting  point  of  a  vesical  calculus.  It  is 
therefore  always  preferable  to  use  catgut  for  the  inner  row  of  sutures 
in  all  operations  on  the  bladder  wall. 

Treatment. — The  treatment  is  removal  either  through  the  cystoscope 
when  possible  or  through  a  suprapubic  cystotomy  wound. 

DISEASES  OF  THE  BLADDER. 

Cystitis. — Cystitis  is  inflammation  of  the  mucous  membrane  of  the 
bladder.  This  is  an  extremely  common  affection,  and  is  invariably 
occasioned  by  the  introduction  into  the  viscus  of  pathogenic  micro- 
organisms, especially  in  cases  where  the  resistance  of  the  host  to  their 
invasion  has  been  diminished  by  traumatism  or  other  causes.  These 
may  gain  entrance  by  an  extension  upward  of  an  inflammatory  process 
from  the  urethra,  or  downward  from  the  kidney,  by  the  introduction 
of  urethral  or  bladder  instruments,  by  the  rupture  of  an  infected  focus 
into  the  bladder,  by  the  transmission  through  diseased  tissues  of 
bacteria,  or  by  the  blood  or  lyniph  channels. 

Exclusive  of  the  tuberculous  form  of  the  disease,  the  following 
micro-organisms  are,  in  the  order  of  their  frequency,  most  commonly 
responsible  for  the  disorder:  the  gonococcus,  the  colon  bacillus, 
Streptococcus  pyogenes,  Staphylococcus  pyogenes,  Diplococcus  urea? 
liquefaciens,  and  the  typhoid  bacillus.  In  chronic  cases  anaerobes 
are  frequently  found  associated  with  these  organisms.  Some  of  these 
organisms  have  the  power  of  decomposing  urea,  setting  free  ammonia, 
and  thereby  rendering  the  urine  alkaline.  Certain  factors  act  as 
predisposing- causes  of  the  disease  and  serve  to  prevent  resolution 
after  the  inflammation  has  occurred.  These  are:  the  presence  in  the 
bladder  of  tumors,  calculi  or  other  foreign  bodies,  and  obstruction  to 
the  normal  outflow  of  the  urine  by  prostatic  or  urethral  disease.  The 
process  often  may  be  limited  to  the  region  of  the  trigone  (tri gonitis), 
or  to  other  special  areas  of  the  bladder.     If  the  inflammation  is  limited 


DISEASES  OF   THE  BLADDER  651 

in  the  mucous  coat,  this  is  thickened  and  reddened,  and  minute 
ulcerations  and  hemorrhages  may  occur,  especially  in  cases  in  which 
calculi  or  other  foreign  bodies  are  present.  Interstitial  cystitis  and 
pericystitis  occasionally  occur  as  a  result  of  an  extension  outward 
through  the  mucous  coat  of  a  severe  gonorrheal  or  septic  infection. 
This  results  in  great  thickening  of  the  bladder  walls  and  contraction 
of  the  organ,  often  to  the  capacity  of  a  few  drachms. 

Symptoms. — In  acute  cystitis  there  are  localized  pain  and  a  frequent 
desire  to  urinate.  The  pain  may  be  constant,  as  a  dull  ache  or  feeling 
of  discomfort  over  the  pubes  or  in  the  perineum;  or  it  ma}'  be  limited 
to  the  act  of  micturition,  when  it  radiates  along  the  urethra,  and  occurs 
with  greatest  intensity  at  the  close  of  the  act,  when  it  is  often  felt  as 
a  scalding  or  burning  sensation. 

Vesical  tenesmus,  Or  straining  to  eject  the  last  drop,  and  a  feeling 
of  more  to  come  after  the  bladder  has  been  emptied,  is  characteristic 
of  the  severer  types  of  the  affection,  and  actual  incontinence  is  often 
associated  with  it;  these  cases  also  are  often  accompanied  by  fever 
and  malaise;  the  patient  becomes  exhausted  from  loss  of  sleep,  owing 
to  the  frequent  calls  to  urinate.  In  the  milder  forms  of  the  disease 
there  may  be  only  a  slight  frequency  in  urination,  and  the  patient  may 
be  unaware  of  the  presence  of  disease  until  his  attention  is  called 
to  it  by  his  medical  adviser.  Tenderness  on  pressure  over  the  pubes 
and  over  the  base  of  the  bladder  or  rectum  sometimes  may  be  elicited. 
In  all  cases  of  cystitis  pus  is  present  in  the  urine.  It  may  be  small  in 
amount,  giving  rise  to  only  a  slight  cloudiness,  or  it  may  be  present 
in  such  quantities  as  to  produce  a  thick,  creamy  precipitate  on  standing. 
In  addition  to  the  pus,  squamous  epithelium,  mucus,  and  blood  are 
often  found.  If  decomposition  has  taken  place,  the  urine  is  ammoni- 
acal,  neutral  or  alkaline  in  reaction,  and  contains  crystals  of  the 
triple  phosphates.  In  the  chronic  forms  of  the  disease  the  pain 
and  constitutional  symptoms  are,  as  a  rule,  wanting.  Slight  frequency 
may  exist;  the  urine  is  cloudy,  generally  ammoniacal,  and  presents  a 
sediment  of  a  thick,  ropy  material  resembling  mucin. 

Diagnosis. — While  pain,  frequency  of  micturition,  vesical  tenesmus, 
and  pyuria  constitute  the  characteristic  symptoms  of  cystitis,  they 
are  also  present  in  other  conditions,  as  pyelitis,  posterior  urethritis, 
suppurative  prostatitis  when  the  abscess  communicates  with  the 
urethra,  and  in  seminal  vesiculitis.  In  pyelitis  the  pain  and  frequency 
are  rarely  severe,  and  are  often  absent,  the  amount  of  pus  is  greater 
than  in  cystitis,  the  urine  may  be  acid,  is  generally  albuminous,  and 
bladder  epithelia  are  not  in  excess.  In  posterior  urethritis  the  pain, 
frequency,  and  tenesmus  are,  as  a  rule,  more  severe,  the  amount  of 
pus  is  comparatively  small,  and  the  prostatic  urethra  may  be  tender 
to  rectal  palpation.  If  the  urine  is  passed  into  two  glasses,  the  first 
urine  contains  more  pus  than  the  second,  and  in  addition  numerous 
shreds  of  rolled-up  pus  or  mucus.  In  prostatitis  with  a  discharge  of 
pus  into  the  urethra  there  is  generally  a  history  of  severe  pain,  tenes- 


652      DISEASES  OF   THE  BLADDER  AND   URETHRA 

mus  and  retention,  followed  by  sudden  relief  and  the  appearance  in 
the  urine  of  a  large  quantity  of  pus.  The  enlarged  and  tender  prostate 
can  also  be  felt  by  the  rectum;  bladder  elements  are  not  in  excess,  and 
the  pain,  frequency,  and  tenesmus,  if  they  continue  at  all,  are  mild  in 
character.  Seminal  vesiculitis  rarely  gives  rise  to  marked  pyuria, 
and  in  the  presence  of  acute  symptoms  the  enlarged  and  tender  vesicle 
can  always  be  felt  by  rectal  examination.  In  acute  cystitis  cystos- 
copy is  difficult  on  account  of  bladder  intolerance  and  often  is  inadvis- 
able. The  appearance  of  the  bladder  mucous  membrane  is  usually 
characteristic.  The  changes  most  frequently  found  are  engorgement 
and  blurring  of  the  bloodvessels,  intense  reddening  and  hemorrhages. 
In  the  more  chronic  forms  the  cystoscope  should  always  be  used  as 
an  aid  to  diagnosis. 

Treatment. — In  the  acuter  forms  of  the  disease  rest  in  bed,  the 
ingestion  of  a  large  amount  of  pure  water,  the  internal  administration 
of  urotropin  in  doses  of  from  7  to  15  grains  two  or  three  times  a  day, 
and  supporitories  of  opium  or  morphine,  constitute  the  early  treat- 
ment. Belladonna  is  useful  to  allay  tenesmus  and  the  bowels  should 
be  kept  freely  open.  If  the  symptoms  do  not  quickly  subside,  the 
bladder  should  be  washed  out  once  or  twice  each  day  with  a  saturated 
solution  of  borax  or  boric  acid,  followed  by  a  solution  of  silver  nitrate 
in  a  strength  of  1  to  8000  to  1  to  3000.  Or  this  treatment  may  be  com- 
bined with  the  instillation  of  smaller  quantities  of  a  stronger  solution. 
The  use  of  potassium  permanganate,  protargol,  or  argyrol  is  also  to  be 
recommended,  but  they  are  inferior  to  the  silver  nitrate  in  the  majority 
of  cases.  These  solutions  should  be  introduced  through  a  sterile 
soft-rubber  catheter  passed  with  the  greatest  gentleness  and  under 
the  strictest  aseptic  precautions.  Hot  sitz  baths  are  often  helpful 
in  allaying  pain  and  muscular  spasm.  In  addition  to  the  above 
treatment,  the  cause  of  the  cystitis,  if  still  present,  must  be  sought  for 
and  removed,  as  well  as  any  factor  which  prevents  or  retards  recovery, 
as  stricture,  stagnation  of  urine,  etc.  Serum  and  vaccine  therapy 
has  been  recently  suggested  in  the  treatment  of  cystitis.  The 
bacteriology  of  the  urine  should  first  be  carefully  studied.  The 
autogenous  vaccines  give  the  best  results  and  should  be  administered 
either  simple  or  mixed  in  small  frequently  repeated  doses.  The  size 
of  the  dose  should  be  gradually  increased,  care  being  taken  to  avoid 
any  severe  constitutional  disturbance. 

As  chronic  cystitis  is  almost  always  dependent  upon  some  definite 
cause,  as  stricture,  prostatic  hypertrophy,  pyelitis,  or  calculus,  the 
treatment  of  these  conditions  is  of  the  highest  importance,  and  should 
always  be  associated  with  the  local  measures  addressed  to  the  bladder. 

Bacteriuria. — Bacteriuria  is  a  name  given  to  a  condition  which  is 
characterized  by  the  presence  in  the  urine  of  large  quantities  of  bacteria, 
which,  however,  have  little  or  no  tendency  to  create  an  inflammation 
of  the  mucous  membrane  of  the  bladder.  Any  chronic  condition 
which  tends  to  produce  lowered  resistance  may  act  as  a  predisposing 


DISEASES  OF  THE  BLADDER  653 

cause.  The  bacteria  may  be  remittently  or  continuously  present. 
The  micro-organisms  apparently  grow  in  the  urine,  the  contamination 
taking  place  from  some  small  focus.  This  focus  is  usually  located  in 
the  kidney,  and  is  due  to  one  or  more  insignificant  septic  infarcts, 
caused  by  some  mild  blood  infection.  Other  sources  of  infection  may 
be  found  in  the  seminal  vesicles,  in  a  follicular  abscess  of  the  prostate, 
the  sinus  pocularis,  or  one  of  the  ejaculatory  ducts.  From  these 
sources  a  certain  number  of  micro-organisms  are  constantly  dis- 
charged into  the  bladder.  The  organism  present  in  eighty  per 
cent,  of  these  cases  is,  according  to  the  observations  of  Jeanbrau, 
the  colon  bacillus;  next  in  frequency  is  the  Staphylococcus  albus; 
Bacillus  typhosus,  Bacillus  subtilis,  and  the  proteus  have  also  been 
reported.  The  micro-organisms  multiply  rapidly,  develop  toxins 
which  may  become  a'bsorbed,  and  give  rise  to  more  or  less  local  dis- 
comfort, mental  depression,  and  general  ill-health.  The  urine  is 
cloudy  and  often  foul  smelling.  It  frequently  has  a  characteristic  smoky 
opalescent  appearance  caused  by  the  emulsification  of  its  countless 
bacterial  content.  On  microscopic  examination  very  few  pus-cells 
are  found,  but  large  quantities  of  bacteria  are  invariably  present. 

The  symptoms  are  rather  indefinite;  occasionally  there  is  fever, 
frequency  in  urination,  with  more  or  less  pain.  More  often  local 
symptoms  are  absent,  and  only  a  general  feeling  of  ill-health  or 
neurasthenia  may  be  present. 

The  treatment  should  consist  in  finding  the  original  focus  and 
removing  it.  Washing  out  the  bladder  is  of  no  value.  If  the  focus 
is  located  in  the  prostatic  urethra,  deep  injections  of  silver  nitrate  and 
massage  may  be  of  benefit.  If  the  focus  cannot  be  found,  the  system- 
atic internal  use  of  urotropin  often  will  bring  about  a  cure.  Whenever 
possible  an  autogenous  vaccine  should  be  made  and  administered. 

Hematuria. — While  hematuria  is  only  a  symptom,  it  occurs  so 
frequently  in  connection  with  grave  genito-urinary  lesions  that  a  brief 
consideration  of  its  causes  may  not  be  out  of  place. 

Hematuria  may  arise  from  lesions  of  the  urethra,  prostate,  bladder, 
ureter,  or  kidney.  In  hemorrhage  from  the  anterior  urethra  the  blood 
flows  continuously  from  the  meatus  and  does  not  contaminate  the 
bladder  urine.  Blood  from  the  posterior  urethra  flows  backward 
into  the  bladder  and  does  not,  as  a  rule,  appear  at  the  meatus.  Urethral 
hemorrhage  may  be  caused  by  trauma  from  external  violence  or  from 
the  use  of  instruments;  from  new  growths  or  a  granular  posterior 
urethritis.  It  may  also  occur  as  a  late  symptom  in  malignant  disease 
of  the  prostate.  In  these  cases,  where  the  source  of  the  bleeding  is  in 
the  posterior  urethra,  the  bladder  urine  is  uniformly  discolored,  but 
the  last  few  drops  passed  may  be  almost  pure  blood. 

Hemorrhage  of  the  bladder  may  be  due  to  trauma,  external  or 
internal;  to  hyperacute  inflammatory  conditions,  to  calculus,  to 
tuberculosis,  to  new  growth,  or  to  the  sudden  relief  of  an  extreme 
retention.     The  amount  of  blood,  as  a  rule,  is  greatest  in  new  growth, 


654  DISEASES  OF   THE  BLADDER  AND   URETHRA 

least  in  inflammatory  conditions;  when  due  to  calculus,  the  amount 
is  generally  between  these  two  extremes.  In  vesical  hematuria  the 
urine  is  uniformly  mixed  with  the  blood,  except  in  the  severest  cases, 
where  it  may  be  present  in  such  large  amount  as  to  produce  clots. 
If  the  lesion  is  situated  in  the  trigone,  the  last  few  drops  passed  may 
be  pure,  bright  blood. 

Hemorrhage  from  the  kidney  may  be  caused  by  trauma,  inflam- 
matory conditions,  especially  the  acute  hematogenous  infections, 
calculus,  aneurism,  or  new  growth.  If  the  hemorrhage  is  abundant, 
renal  colic  is  produced  from  the  passage  of  clots  along  the  ureter. 
These  long,  worm-like  clots  sometimes  may  be  seen  in  the  bladder 
by  the  cystoscope,  and  are  occasionally  passed  during  urination. 
If  the  amount  of  blood  is  small,  the  urine  may  be  slightly  or  not  at  all 
discolored;  if  larger  in  amount,  the  urine  appears  smoky;  if  the  hemor- 
rhage is  very  abundant,  the  color  is  brighter,  and  ureteral  clots  are 
present. 

All  of  these  conditions  are  described  at  length  in  the  other  sections. 

Of  the  other  rarer  forms  of  hematuria,  there  may  be  mentioned 
the  hematuria  of  scurvy,  of  malaria,  of  a  chronic  interstitial  nephritis, 
and  that  due  to  parasites.  A  form  of  essential  hematuria  occurs 
which  has  been  ascribed  to  small  areas  of  chronic  nephritis  or  erosion 
of  the  vessels  of  the  renal  pelvis.  It  is  usually  unilateral  and  often 
ceases  entirely  after  exploratory  nephrotomy. 

Of  the  parasitic  diseases,  two  are  well  recognized  as  being  the  cause 
of  hematuria,  the  Filaria  sanguinis  hominis  and  theBilharzia  hematobia. 

Filaria  Sanguinis  Hominis. — This  worm  is  supposed  to  enter  the 
human  body  by  drinking-water  or  through  inoculation  by  mosquitos, 
in  the  bodies  of  which  the  embryos  primarily  develop.  The  adult 
worms  inhabit  the  lymphatics  and  reproduce  each  night  hundreds 
of  fresh  embryos,  which  may  be  detected  in  the  blood  by  the  micro- 
scope. The  parent  worms  occasionally  may  be  found  in  the  lymphatic 
vessels,  but  never  in  the  blood.  They  are  long,  thread-like,  translucent 
bodies.  The  female  is  much  larger  than  the  male,  and  may  measure 
two  or  three  inches  in  length.  The  parent  worms  cause  obstruction 
in  the  larger  lymphatic  vessels  by  their  presence  alone,  or  by  an  inflam- 
matory thickening  which  their  presence  begets.  When  the  thoracic 
duct  or  some  large  mesenteric  tributary  is  thus  obstructed,  dilatation 
of  the  peripheral  branches  causes  extensive  lymphedema  or  lymph- 
angiomata,  which  may  rupture,  giving  rise  to  chylous  ascites,  chylous 
hydrocele,  or  chyluria.  Lesions  which  rupture  into  the  urinary  passages 
may  also  give  rise  to  an  associated  hematuria. 

The  disease  is  common  in  tropical  countries,  but  rare  in  the  United 
States  or  on  the  continent  of  Europe. 

Bilharzia  Hematobia. — The  disease  prevails  extensively  in  Africa, 
in  India,  and  in  a  few  other  tropical  localities.  Two  or  three  cases 
have  been  reported  which  apparently  developed  in  the  central  portion 
of  the  United  States.     The  Bilharzia  hematobia  is  a  fluke  10  to  20 


DISEASES  OF   THE  BLADDER  655 

mm.  in  length,  the  female  being  larger  than  the  male.  It  enters  the 
human  body  by  drinking-water.  The  adult  worms  inhabit  the  venous 
system,  particularly  the  portal.  The  female  deposits  large  numbers 
of  eggs  in  the  smaller  vessels,  which  eventually  cause  a  rupture  of  the 
vessel  and  the  escape  of  the  ova  into  the  tissues,  where  they  give  ri>e 
to  various  lesions.  Most  of  these  lesions  occur  in  the  urinary  tract, 
and  may  be  found  in  the  kidneys,  the  ureters,  bladder,  and  urethra. 
The  lesions,  tor  the  most  part,  consist  in  hyperemic  patches  or  papillo- 
matous granulations. 

The  chief  symptom  of  the  disease  is  an  abundant  and  persisting 
hematuria.  Calculi  frequently  develop  and,  in  the  advanced  stages 
of  the  disease,  inflammatory  lesions,  abscesses,  and  urinary  fistula?. 

As  in  many  other  parasitic  diseases,  blood  examinations  in  these 
show  a  moderate  leukocytosis  with  a  high  percentage  of  eosinophiles. 

Treatment. — In  regard  to  the  treatment  of  these  parasitic  diseases, 
little  or  nothing  can  be  accomplished  by  drugs,  except  to  relieve  the 
painful  terminal  symptoms.  In  a  few  instances  of  filiarisus  the  finding 
and  surgical  removal  of  one  or  more  parent  worms  in  a  mass  of  dilated 
lymphatics  has  greatly  relieved  the  symptoms,  and  although  one  can 
never  be  sure  that  other  worms  are  not  present,  an  attempt  to  find 
and  remove  them  is  justifiable. 

Tuberculosis  of  the  Bladder — While  tuberculosis  may  occur  pri- 
marily in  any  part  of  the  genito-urinary  tract,  there  is  a  growing  belief 
among  surgeons  that,  in  the  vast  majority  of  instances,  it  makes  its 
first  appearance  either  in  the  kidney  or  the  epididymis.  From  each 
of  these  locations  it  progresses  toward  the  bladder,  following  in  each 
instance  the  direction  of  the  fluid  current  in  the  ureter  or  vas  deferens. 
The  disease  may  also  reach  the  bladder  by  direct  involvement  through 
its  wall  from  a  diseased  prostate.  As  the  route  from  the  kidney 
to  the  bladder  is  shorter  and  more  direct  than  from  the  epididymis, 
and  as  renal  tuberculosis  is  of  more  frequent  occurrence  than  tubercu- 
lous epididymitis,  bladder  tuberculosis  is  more  frequently  a  sequel 
of  kidnev  disease.  As  early  tuberculosis  of  the  kidney  and  epididymis 
gives  rise,  as  a  rule,  to  no  painful  symptoms,  the  irritation  produced 
by  the  secondary  lesion  in  the  bladder  is  often  the  first  indication 
of  the  pathologic  condition,  and  for  that  reason  the  primary  lesion  is 
not  infrequently  overlooked.  The  disease,  as  a  rule,  is  located  in  the 
vicinity  of  the  trigone;  if  secondary  to  involvement  of  one  kidney,  the 
region  surrounding  the  orifice  of  its  ureter  is  first  invaded.  The  dis- 
ease primarily  appears  in  the  form  of  miliary  tubercles,  which  coalesce, 
forming  indurated  areas  or  ulcers  with  infiltrated  borders.  These  may 
extend  and  form  larger  ulcerated  areas,  from  which  shreds  of  necrotic 
tissue  may  be  cast  off  and  appear  in  the  urine.  Secondary  infection 
with  pyogenic  organisms  is  common.  The  pelvic  lymph  nodes  are 
usually  affected  by  the  tuberculous  process. 

Symptoms. — Tuberculosis  of  the  bladder  may  remain  latent  for 
a  long  period,  and  only  give  rise  to  symptoms  on  the  occurrence 


656  DISEASES  OF   THE  BLADDER  AND   URETHRA 

of  a  secondary  infection  or  source  of  irritation.  Thus  the  occurrence 
of  an  acute  gonorrhea  or  the  passage  of  an  unclean  sound  or  catheter 
may  give  rise  to  a  cystitis  which  may  awaken  a  latent  tuberculosis 
and  render  the  diagnosis  exceedingly  obscure.  The  symptoms  are 
those  of  a  slowly  developing  cystitis;  frequency  in  urination,  pain  at 
the  close  of  the  act,  slight  tenesmus,  and  the  presence  of  pus  and  blood 
in  the  urine.  These  symptoms  progressively  increase  in  severity, 
slowly  at  first,  but  more  rapidly  toward  the  end.  There  is,  as  a  rule, 
a  gradual  deterioration  of  the  general  health,  with  afternoon  fever, 
occasional  sweats,  and  loss  of  weight  and  strength.  As  the  disease 
progresses  the  bladder  symptoms  become  more  marked,  the  pain  is 
constant,  and  the  calls  to  urinate  become  more  frequent  until  the 
urine  is  almost  continuously  expelled  by  frequent  spasmodic  efforts, 
each  of  which  is  accompanied  by  excruciating  pain  and  tenesmus. 
An  absolute  diagnosis  of  tuberculosis  can  only  be  made  by  the  demon- 
stration of  tubercle  bacilli  in  the  urinary  sediment,  either  by  the 
microscope  or  as  a  result  of  animal  inoculation.  In  case  of  doubt 
several  examinations  should  be  made.  In  the  earliest  stage  of  the 
affection  the  cystoscope  will  show  an  edematous  hyperemic  area 
about  the  mouth  of  the  affected  ureter.  Later,  the  disease  extends 
over  the  trigone  and  toward  the  other  ureter,  and  at  a  still  later  period 
characteristic  miliary  tubercles  and  ulcerations  may  be  seen. 

Treatment. — As  a  rule,  all  local  measures  serve  only  to  exaggerate 
the  symptoms  and  cause  the  disease  to  advance  with  greater  rapidity. 
In  the  early  stages,  an  out-of-door  life  among  the  pines  in  a  high 
altitude  or  a  long  sea-voyage  will  often  produce  a  rapid  and  marked 
improvement  in  all  the  symptoms.  Not  infrequently  such  patients 
may  live  for  years  under  these  conditions  in  comparative  comfort; 
but  as  soon  as  city  life  is  resumed  the  symptoms  reappear  and  the 
disease  progresses.  General  tonic  measures,  creosote,  cod-liver  oil, 
iron,  and  arsenic  are  indicated.  Sometimes  injections  of  tuberculin 
may  prove  beneficial.  If  the  pain  becomes  unbearable,  permanent 
suprapubic  drainage  is  to  be  recommended  Early  suprapubic  cystot- 
omy with  direct  application  of  strong  antiseptic  agents  to  the  local 
lesions  has  been  frequently  recommended,  but  the  results  of  this 
method  of  treatment  are  disappointing.  While  local  measures  in  this 
disease  are  of  little  or  no  value  and  render  the  patient  liable  to  the 
dangers  of  secondary  infection,  brilliant  results  are  often  obtained 
here  as  in  other  tuberculous  affections  by  the  early  recognition  and 
removal  of  the  primary  focus.  If  it  can  be  shown  by  the  cystoscope 
that  the  disease  is  limited  to  the  region  of  one  ureteric  orifice,  and  that 
the  urine  from  the  opposite  kidney  is  normal,  nephrectomy  will  often 
bring  about  a  cure  of  the  bladder  lesion. 

After  nephrectomy,  Rovsing  recommends  the  injection  into  the 
bladder  of  a  warm  solution  of  carbolic  acid,  and  retaining  it  for  three 
or  four  minutes.  About  50  c.c.  of  the  solution  should  be  employed 
and  the  treatment  repeated  three  or  four  times. 


DISEASES  OF  THE  BLADDER 


657 


Calculus. — Stone  in  the  bladder  is  a  fairly  common  disease  in  certain 
regions.  It  seems  to  be  more  frequently  observed  in  the  tropics, 
possibly  on  account  of  the  abundant  perspiration  and  consequent 
concentration  of  the  urine,  also  in  limestone  districts,  on  account  of 
the  greater  quantity  of  mineral  salts  ingested  in  the  drinking-water. 
It  occurs  with  greater  frequency  in  childhood  and  old  age  than  in 
middle  life.  It  is  commoner  in  men  than  in  women.  In  an  aseptic 
condition  of  the  urinary  passages  calculi  rarely  form  in  the  bladder, 
but  are  carried  downward  from  the  kidney,  lodge  in  the  bladder,  and 
gradually  increase  in  size.  They  may  be  single  or  multiple.  If 
cystitis  is  present,  however,  calculi  may  develop  in  the  bladder. 
The  stone  may  lie  in  a  diverticulum  of  the  bladder  wall  or  a  spasmodic 
contracture  of  the  bladder  around  the  stone  may  take  place  giving  rise 


Fig.  301. — Vesical  calculus.    Weight,  74  grams. 


to  the  formation  of  the  so-called  hour-glass  bladder.  The  methods 
of  urinary  calculus-formation  have  been  described  in  the  preceding 
chapter,  and  will  not  be  repeated  here. 

Varieties. — Vesical  calculi  may  be  composed  wholly  of  uric  acid, 
in  which  case  they  are  round  or  oval,  of  a  dark  brown  color,  and 
with  a  comparatively  smooth  surface;  or  of  ammonium  urate,  when,  as 
a  rule,  they  are  lighter  in  color;  or  of  calcium  oxalate,  the  mulberry 
calculus,  an  exceedingly  hard,  dark  brown  or  black  stone,  with  a 
rough,  irregular,  nodular  surface;  or  of  the  phosphates  (a  mixture 
of  phosphate  of  lime  and  the  triple  phosphates),  these  are  white 
and  friable,  and  form  in  the  decomposed  urine  of  cystitis.  It  frequently 
happens  that  a  calculus  has  a  nucleus  of  uric  acid  or  oxalate  of  lime, 
while  the  outer  layers  are  phosphatic  (Figs.  301  and  302).  This  change 
42 


658 


DISEASES  OF   THE  BLADDER  AND   URETHRA 


in  the  development  of  a  calculus  generally  indicates  the  occurrence  of  a 
bladder  infection.     Cystine  and  xanthine  calculi  are  rare. 

Symptoms. — The  amount  of  disturbance  produced  by  the  presence 
of  a  calculus  in  the  bladder  varies  according  to  the  kind  of  calculus 
and  the  tolerance  of  the  mucous  membrane.  Thus,  a  rough  heavy 
stone  will,  as  a  rule,  produce  more  irritation  than  a  smooth  light  one, 
and  a  damaged  bladder  will  react  more  promptly  and  violently  than 
a  healthy  organ.  Children,  as  a  rule,  experience  relatively  "more 
discomfort  from  stone  than  older  people,  and  active  individuals 
more  than  those  who  live  a  sedentary  life.  Although  cystitis  is 
generally  present  in  patients  suffering  with  calculus,  it  is  almost 
always  the  result  of  infection  from  without  if  the  calculus  originally 


Fig.  302. — Vesical  calculus  bisected. 


developed  in  a  sterile  bladder.  It  usually  follows  the  passage  of  some 
instrument  for  purposes  of  diagnosis  or  treatment,  and  when  it  occurs 
it  increases  to  a  marked  extent  the  vesical  irritability  and  other 
painful  symptoms.  In  children  the  symptoms  of  stone  in  the  bladder 
are  frequent  and  painful  micturition,  vesical  and  rectal  tenesmus, 
often  with  prolapse  of  the  mucous  membrane  of  the  bowel.  The 
child  is  restless,  nervous,  and  irritable,  cries  with  pain  at  each  act  of 
urination  and  is  constantly  handling  the  penis  or  pulling  at  the  prepuce. 
In  adults  there  is  often  a  preceding  history  of  gravel  and  attacks  of 
renal  colic.  If  the  calculus  forms  under  sterile  conditions  of  the 
urinary  tract,  there  may  be  for  a  long  period  no  symptoms  other  than 
a  slight  diurnal  frequency  in  urination  during  or  following  severe 
physical  exertion.     As  a  rule,  however,  there  is  vesical  irritability, 


DISEASES  OF  THE  BLADDER 


659 


evidenced  by  an  increase  of  frequency  of  urination,  with  slight  tenesmus 
and  a  pain  in  the  glans  penis  at  the  close  of  the  act  of  micturition. 
These  symptoms  are  aggravated  by  bodily  exercise  and  by  riding, 
especially  over  a  rough  pavement  or  road ;  they  are  relieved  by  rest 
and  change  of  position,  and  seldom  appear  at  night.  Later,  hematuria 
may  occur,  generally  as  a  result  of  some  unusual  exertion,  it  is  usually 
scanty  and  observed  at  the  end  of  micturition.  The  general  health 
remains  perfect  and  the  urine  contains  little  or  no  pus.  If  after  the 
introduction  of  a  sound  or  searcher,  or  if  from  any  other  cause  the 
bladder  becomes  infected,  the  clinical  picture  at  once  changes;  the 
pain  is  greatly  increased  in  severity,  the  calls  to  urinate  are  more 
frequent,  and  the  tenesmus  is  increased.  The  symptoms  now  are 
present  at  night  as  well  as  during  the  day,jthe  urine  contains  pus  and 
"blood,  and  there  may  be  fever  and  sweats.  The  patient  becomes 
exhausted  from  lack  of  sleep  owing  to  the  frequent  calls  to  urinate, 
and  loses  flesh  and  strength.  If  urethral  obstruction  exists,  the  disease 
may  extend  upward  to  the  kidneys  and  give  rise  to  septic  pyeloneph- 
ritis, uremia,  and  general  sepsis. 

Diagnosis. — An    absolute    diagnosis    of    stone    in    the    bladder   can 
only  be  made  by  the  cystoscope  or  by  touching  the  calculus  with  a 


Fig.  303. — Thompson  searcher. 


metallic  sound  or  searcher.  The  Thompson  searcher  (Fig.  303)  is 
the  best  instrument  for  this  purpose.  The  patient  should  lie  on 
a  table  with  the  hips  raised  on  a  pillow  or  cushion.  The  bladder 
should  contain  about  6  ounces  of  sterile  fluid.  The  searcher  should 
be  carefully  introduced  with  the  beak  upward  and  carried  back  to 
the  fundus;  it  should  then  be  turned  from  side  to  side,  and  gently 
drawn  forward  and  backward  until  the  entire  region  of  the  fundus 
has  been  thoroughly  explored,  after  which  the  beak  should  be  turned 
downward  to  explore  the  pocket  which  often  exists  just  behind  the 
prostate  if  enlarged.  If  a  calculus  lies  free  in  the  bladder,  contact 
with  the  metal  searcher  will  give  a  distinct  click,  which  can  be  both 
felt  and  heard.  It  occasionally  happens  that  a  stone  is  lodged  in  a 
diverticulum,  in  which  case  the  most  careful  examination  with  a 
searcher  may  fail  to  detect  its  presence.  In  these  instances  the 
cystoscope  will  often  reveal  the  nature  of  the  disease  after  all  other 
diagnostic  means  have  failed.  As  in  other  portions  of  the  urinary 
tract,  the  z-rays  will  often  demonstrate  the  presence  of  a  calculus 
in  the  bladder.  The  shadow  is  usually  in  the  midline  when  the  patient 
is  in  the  dorsal  position  and  if  lateral  may  indicate  that  the  stone  is 
imbedded  in  a  diverticulum. 


660 


DISEASES   OE   THE   BLADDER   AND    URETHRA 


Treatment. — Except  in  cases  in  which  the  physical  condition  of 
the  patient  is  such  as  to  preclude  the  possibility  of  any  operative 
procedure,  the  indication  is  in  every  instance  to  remove  the  stone. 
Several  methods  are  at  present  in  use  to  accomplish  this  end,  each 
having  its  advantages  and  disadvantages,  and  each  applicable  to 
certain  conditions  of  the  patient.  These  will  be  considered  in  the 
order  of  their  frequency  of  application. 


Fig.  304. — Bigclow  lithotrite. 

I/itholapaxy,  or  rapid  lithotrity  with  immediate  evacuation  of  the 
fragments.  This  operation  consists  in  crushing  the  stone  by  means 
of  a  lithotrite  (Fig.  304),  followed  by  removal  of  the  fragments  with 
an  evacuator  (Fig.  305).  The  patient  should  be  placed  on  a  table 
with  the  hips  slightly  raised;  the  bladder  should  be  emptied  and  0 
ounces  of  warm  boric  acid  solution  introduced.     The  closed  lithotrite 


Fiu.  305. — Chismoro  evacuator. 


should  then  be  carefully  passed  into  the  bladder  and  the  angle  of 
its  beak  allowed  to  rest  in  the  median  line  upon  the  floor  of  the  organ 
near  its  fundus.  The  male  blade  should  then  be  slowly  drawn  back- 
ward while  the  beak  of  the  instrument  is  depressed  into  the  most 
dependent  portion  of  the  vesical  pouch;  the  instrument  is  then  closed 
by  pushing  the  male  blade  into  place.  Usually  the  stone  is  caught 
after  one  or  two  such  attempts;  if  not,  the  lithotrite  is  rotated  to  one 


DISEASES  OF  THE  BLADDER  661 

side  or  the  other,  and  the  same  procedure  repeated  after  first  locating 
the  stone  with  the  closed  instrument.  When  the  stone  is  firmly 
grasped  between  the  jaws  of  the  lithotrite  it  is  crushed  by  slowly 
forcing  the  blades  together  with  the  handle  screw.  This  process  is 
repeated  many  times  until  the  calculus  is  reduced  to  small  fragments. 
The  lithotrite  is  then  withdrawn  and  the  evacuating  catheter  intro- 
duced, and  after  allowing  an  ounce  or  two  of  the  fluid  to  escape,  the 
evacuating  syringe,  filled  with  warm  boric  acid  solution,  is  attached 
and  from  1  to  2  ounces  of  fluid  forced  into  the  bladder  and  withdrawn 
by  alternate  compression  and  relaxation  of  the  rubber  bull).  By  this 
means  the  fragments  are  aspirated  into  the  glass  receptacle  at  the 
bottom  of  the  evacuating  syringe.  The  presence  of  large  fragments 
which  cannot  be  aspirated  through  the  tube  is  indicated  by  their 
clicking  against  the  tube  during  the  evacuating  process.  When 
these  are  present,  the  lithotrite  is  again  introduced  and  these  fragments 
further  broken  up  and  evacuated.  When  the  bladder  is  emptied 
of  fragments,  it  should  be  thoroughly  cleansed  by  a  careful  washing 
with  warm  boric  acid  solution  and  the  patient  subsequently  treated  by 
diuretics,  bladder  irrigation,  and  anodynes  if  pain  and  cystitis  are  present. 

In  this  operation  care  should  be  taken  to  avoid  injury  of  the  mucous 
membrane  by  including  it  between  the  blades  of  the  lithotrite  and 
the  stone.  To  prevent  this  accident,  the  bladder  should  be  fairly 
well  distended  with  fluid  (not  less  than  4  ounces),  and  after  the  stone 
is  caught  the  instrument  should  be  freely  rotated  before  crushing. 
This  operation  occasionally  may  be  done  with  cocaine.  Chisniore  and 
Swinburne  have  each  reported  a  series  of  cases  where  the  operation 
has  been  performed  in  this  manner  and  the  patients  subsequently 
treated  as  ambulant  cases.  In  the  majority  of  instances,  however, 
general  anesthesia  is  to  be  advised.  A  small  stone  may  sometimes 
be  removed  directly  through  the  evacuator  without  crushing. 

Suprapubic  Lithotomy. — In  this  operation  the  stone  is  removed 
through  an  opening  in  the  summit  of  the  bladder  by  an  extraperitoneal 
incision  just  above  the  pubis.  After  the  usual  preparation  the 
bladder  is  moderately  distended  with  from  6  to  8  ounces  of  warm 
boric  acid  solution,  and  a  vertical  incision  is  made  in  the  median  line 
just  above  the  symphysis  pubis.  This  is  carried  down  between  the 
two  rectus  muscles  to  the  prevesical  space,  which  is  freely  exposed  by 
lateral  retractors.  The  fold  of  peritoneum  passing  from  the  summit 
of  the  bladder  to  the  anterior  abdominal  wall  is  pushed  upward  if  it 
extends  into  the  field  of  operation,  and  the  bladder  wTall  exposed  by 
tearing  away  the  loose  areolar  tissue  and  veins  with  the  fingers  or  for- 
ceps. Two  stout  silk  sutures  are  then  passed  in  a  vertical  direction 
through  the  wall  of  the  bladder  on  either  side  of  the  median  line 
knotted,  and  held  upward  by  an  assistant.  The  bladder  is  next 
opened  by  a  longitudinal  incision  between  these  two  suture  retractors 
and  the  cavity  explored  with  the  finger,  after  which  the  stone  is  seized 
and  withdrawn  with  forceps.     If  the  bladder  is  not  infected,  an  attempt 


602 


DISEASES  OF   THE  BLADDER  AND    URETHRA 


may  be  made  to  close  the  suprapubic  wound  completely  and  establish 
drainage  by  the  perineal  route.  If  this  is  done,  the  bladder  should 
be  united  with  two  layers  of  sutures,  the  first  of  catgut  uniting  the 
mucous  membrane,  the  second  of  silk  uniting  the  muscular  and  fibrous 

coats.  If  the  bladder  wall  is  thin, 
a  third  row  of  silk  sutures  may  be 
introduced,  infolding  the.  other 
two.  The  muscles  should  next  be 
drawn  together  with  two  or  three 
catgut  stitches  and  the  skin  united 
in  the  usual  manner,  a  small  gauze 
drain  being  left  in  the  lower  angle 
of  the  wound  reaching  to  the  preves- 
ical space,  to  allow  escape  of  the 
urine  if  leakage  should  occur.  If  su- 
prapubic drainage  is  to  be  employed, 
a  rubber  tube  should  be  introduced, 
the  bladder  wound  closed  tightly 
about  it,  and  the  superficial  wound 
packed  with  gauze. 

The  disadvantage  of  suprapubic 
drainage  is  that,  unless  some 
apparatus  is  employed  to  keep 
the  bladder  comparatively  empty, 
the  dressings  are  constantly  wet,  as 
well  as  the  patient's  person  and 
bedding.  This,  however,  can  in 
large  measure  be  prevented  by 
the  use  of  the  siphon  drainage 
(Fig.  30G).  By  allowing  the  water 
from  the  reservoir  to  flow  into 
the  tube  very  slowly  the  loop-trap 
will  be  filled  about  once  every  two 
or  three  minutes;  as  this  empties 
itself  it  sucks  the  fluid  from  the 
bladder. 

As  soon  as  the  wound  begins  to 
granulate  the  tube  may  be  removed 
and  a  smaller  one  substituted,  or  it 
may  be  left  out  altogether  and  the 
wound    allowed    to    heal.     Healing 
takes   place,  under   favorable    con- 
ditions, in  from  two  to  three  weeks. 
Median  Lithotomy. — In  this  operation  the  bladder  is  entered  through 
the  deep  urethra  by  a  perineal  incision.     The  patient  is  placed  on  his 
back,  the  buttocks  drawn  well  down  to  the  edge  of  the  table  (Fig. 
307),  and  the  thighs  and  knees  acutely  flexed,  and  held  in  this  position 


Fig.  306. — Apparatus  for  siphon 
drainage  of  bladder:  A,  reservoir;  B, 
suprapubic  drainage-tube;  C,  clamp  to 
regulate  flow;  D,  trap  which  allows 
intermittent  siphonage  of  bladder. 
(Dawbarn.) 


DISEASES  OF  THE  BLADDER 


663 


by  two  assistants  or  by  the  Clover  crutch.  A  grooved  staff  (Fig. 
308)  is  introduced  into  the  urethra  and  held  by  an  assistant,  who 
also  draws  up  the  scrotum,  freely  exposing  the  perineum.  The  surgeon, 
seated  in  front  of  the  patient,  makes  a  median  longitudinal  incision 
in  the  perineum,  and  divides  the  tissues  down 
to  the  bulb.  The  groove  of  the  staff  is  next  felt 
just  below  the  bulb,  and  the  knife  pushed 
through  the  urethra  into  the  groove  and  the 
urethral  tissue  incised  for  a  distance  of  about 
three-quarters  of  an  inch  directly  backward 
toward  the  prostate.  A  large  probe-director 
is  then  passed  backward  into  the  bladder 
and  the  staff  withdrawn.  The  urethra  is 
next  dilated  by  means  of  a  pair  of  dressing- 
forceps  passed  along  the  director,  and  later 
by  the  surgeon's  forefinger,  which  finally 
enters  the  bladder.  When  the  urethra  is 
sufficiently  dilated  a  pair  of  lithotomy  forceps 
are  introduced  and  the  stone  removed.  A 
rubber  drainage  tube  is  passed  into  the 
bladder  through  the  perineal  opening  and 
held  in  place  by  one  or  two  silk  sutures.  The 
external  wound  is  packed. 

Lateral  Lithotomy. — The  patient  is  prepared 
and  placed  in  the  lithotomy  position  (Fig. 
307).     The  staff  is  introduced  and  an  oblique 


Fig.   307. — Lithotomy  position.      (Roberts.) 


Fig.  308.— Grooved  staff. 


incision  made  beginning  at  the  raphe  two  inches  above  the  anus  and 
carried  downward  and  slightly  outward  for  three  inches,  the  lower 
extremity  reaching  a  point  midway  between  the  lower  margin  of  the 
anus  and  the  tuberosity  of  the  ischium.     This  incision  divides  the 


664      DISEASES  OF   THE  BLADDER  AND   URETHRA 

skin  and  subcutaneous  fat.  The  knife  is  then  plunged  boldly  inward 
to  the  groove  of  the  staff  at  the  upper  limit  of  the  incision,  and,  with 
the  cutting  edge  turned  downward,  is  pushed  through  into  the  bladder. 
As  it  is  withdrawn  the  deep  cut  is  enlarged  downward,  care  being  taken 
to  avoid  wounding  the  rectum.  As  soon  as  the  knife  is  withdrawn  the 
finger  is  passed  into  the  bladder  and  the  stone  felt.  A  pair  of  lithotomy 
forceps  are  then  passed  into  the  bladder  and  the  stone  removed.  After 
all  hemorrhage  is  arrested  a  tube  is  introduced  and  the  wound  packed. 
The  tube  may  be  removed  in  forty-eight  hours.  As  the  wound 
granulates  the  urine  gradually  begins  to  pass  by  the  urethra. 

Choice  of  Operation. — Litholapaxy  should  be  employed  in  middle- 
aged  individuals  in  the  absence  of  severe  cystitis  where  no  urethral 
obstruction  or  prostatic  disease  is  present,  and  where  the  stone  is 
of  moderate  size  and  not  too  hard  to  be  easily  crushed  by  the  lithotrite. 
Suprapubic  lithotomy  should  be  the  operation  of  choice  in  young 
children  and  old  men,  especially  when  prostatic  enlargement  or 
stricture  is  present.  It  should  also  be  employed  if  for  any  reason  a 
rapid  operation  is  essential  to  success,  and  in  all  cases  of  very  large 
stone. 

Median  lithotomy  is  indicated  for  small  and  very  hard  calculi  in 
middle-aged  individuals,  and  when  perineal  drainage  or  exploration 
of  the  prostatic  urethra  is  desirable.  Lateral  lithotomy  is  now  rarely 
employed.  It  is  occasionally  indicated  in  children  if  for  any  reason 
the  suprapubic  operation  seems  unadvisable. 

Vesical  Calculus  in  the  Female. — Vesicle  calculus  in  the  female  is 
rare  on  account  of  the  larger  size  of  the  urethra,  allowing  concretions 
to  pass  at  an  early  stage  in  their  development.  When  present  they 
are  frequently  phosphatic,  and  occasionally  consist  of  a  deposit  of 
phosphatic  salts  around  some  foreign  body  previously  introduced 
through  the  urethra.  Small  calculi  may  be  removed  by  forceps 
through  the  urethra,  which  easily  can  be  dilated  to  the  size  of  the 
forefinger;  larger  stones  should  be  crushed  or  removed  by  the  supra- 
pubic operation. 

TUMORS  OF  THE  BLADDER. 

From  the  most  recent  reliable  statistics  Mandlebaum  states  that 
only  about  0.7  per  cent,  of  all  tumors  occur  in  the  urinary  bladder. 
Men  are  affected  far  more  frequently  than  women,  the  proportion 
being  10  to  1.  About  65  per  cent,  are,  or  eventually  become,  malig- 
nant. It  is  an  interesting  and  well-recognized  fact  that  many  tumors 
which  are  histologically  benign  appear  clinically  to  be  malignant. 
It  has  also  been  observed  that  certain  types  of  histologically  malignant 
growths  pursue  a  remarkably  benign  course,  showing  no  evidence  of 
cachexia  or  metastasis  even  after  several  local  occurrences. 

Of  the  epithelial  tumors,  papillomata  and  carcinomata  are  the 
commonest,  adenomata  and  cysts  are  rare. 


TUMORS  OF  THE  BLADDER  665 

Of  the  connective-tissue  neoplasms,  fibromyxomata  (polyps),  fibro- 
mata, angiomata,  myomata,  and  sarcomata  arc  to  be  considered. 
Dermoids  and  ehondromata  have  been  observed,  hut  ;ire  so  rare  as  to 
be  surgical  curiosities. 

Papilloma. —  Papillomata  may  occur  as  pedunculated  or  sessile 
growths,  may  be  hard  or  soft,  according  to  the  amount  of  connective 
tissue  which  they  contain,  and  may  be  single  or  multiple.  When  the 
softer  tumors  are  placed  in  water  they  are  seen  to  consist  of  large 
branching  processes  which  float  about,  giving  rise  to  the  term  villous 
tumor. 

Fibromyxoma. — Fibromyxomata  occur  almost  exclusively  in  chil- 
dren, and  resemble  the  more  commonly  observed  nasal  polyps. 

Carcinoma. — Carcinomata  occur  in  three  varieties — the  epithelioma 
which  may  so  closely  resemble  the  papilloma  in  its  various  forms  as  to 
be  indistinguishable  except  by  the  microscope;  the  adenocarcinoma, 
and  the  fibrous  or  scirrhous  type,  the  last  two  commonly  have  their 
origin  in  the  prostate.  Infiltration  of  the  base  of  the  tumor  is  usually 
regarded  as  a  sign  of  malignancy. 

Sarcoma. — Sarcoma  generally  arises  in  the  submucous  tissues,  may 
be  hard  or  soft,  and  generally  infiltrates  all  the  tunics  of  the  organ. 

The  majority  of  the  bladder  growths  arise  from  the  region  of  the 
trigone.  This  is  particularly  true  of  the  carcinomata,  many  of  which 
have  their  origin  in  the  prostate.  In  multiple  papillomata  a  secondary 
growth  is  often  found  at  a  point  of  contact  of  the  mucous  membrane 
with  the  primary  growth  when  the  viscus  is  empty. 

Symptoms. — The  two  characteristic  symptoms  of  tumor  of  the 
bladder  are  hematuria  and  vesical  irritability.  As  a  rule,  in  innocent 
tumors  the  order  of  their  appearance  is,  hematuria  first,  frequent 
and  painful  micturition  later;  while  in  malignant  growths  the  dysuria 
generally  appears  first  and  the  hematuria  at  a  subsequent  period. 
Unlike  hematuria  of  calculous  disease,  bleeding  from  tumors  generally 
arises  spontaneously,  often  at  night.  The  hemorrhage  is  more  abun- 
dant in  the  papillomata,  and  may  completely  fill  the  bladder  with  clots, 
producing  retention  and  vesical  tenesmus  to  such  a  degree  that  supra- 
pubic cystotomy  will  be  immediately  necessary.  Innocent  tumors 
may  exist  for  years  without  producing  symptoms  other  than  occasional 
hematuria  and  moderate  vesical  irritability,  and  this  latter  symptom 
may  be  absent  if  the  growth  is  located  at  a  distance  from  the  trigone. 
Obstruction  of  a  ureter  from  clogging  of  its  vesical  orifice  by  the 
growth  of  a  tumor  is  not  infrequent,  and  results  in  hydronephrosis. 
If  the  growth  is  situated  near  the  urethral  orifice,  retention  of  urine 
may  occur.  In  malignant  growths  the  symptoms  are  progressive; 
the  pain  is  present  at  first  only  during  micturition,  later  it  becomes 
continuous;  the  calls  to  urinate  are  increased  in  frequency,  and  blood 
is  constantly  present  in  the  urine.  As  the  disease  progresses  vesical 
tenesmus  becomes  more  marked  and  rectal  pain  develops;  the  urine  is 
expelled  by  spasmodic  effort  every  few  minutes,  each  act  being  accom- 


666      DISEASES  OF   THE  BLADDER  AND   URETHRA 

panied  by  agonizing  pain.  The  patient  rapidly  emaciates,  becomes 
chachectic,  and  finally  dies  of  exhaustion,  uremia,  or  sepsis. 

Cystitis  generally  develops  in  cases  of  bladder  growth,  commonly 
after  an  instrumental  exploration.  This  may  give  rise  to  such  an 
increase  in  the  vesical  irritability  as  to  cause  an  innocent  growth  to 
present  symptoms  strongly  resembling  cancer. 

Diagnosis. — In  the  presence  of  symptoms  indicating  the  possibility 
of  tumor  of  the  bladder,  hematuria,  and  vesical  irritability,  one  must 
consider  three  possibilities:  stone,  tuberculosis,  and  tumor. 

In  stone  the  hemorrhage  is  practically  never  spontaneous,  is  rarely 
profuse,  and  is  generally  the  result  of  some  unusual  bodily  motion; 
the  pain  is  more  acute  at  the  end  of  micturition,  and  is  felt  with  greatest 
intensity  in  the  glans  penis.  The  stone  generally  can  be  detected  by  a 
searcher.  The  general  health  may  not  be  impaired.  In  tuberculosis 
the  cystitis  and  progressive  loss  of  flesh  and  strength  are  the  prominent 
symptoms;  hemorrhage  is  rarely  abundant,  but  is  apt  to  be  fairly 
constant.  The  demonstration  of  bacilli  in  the  urine  by  the  microscope 
or  as  a  result  of  animal  inoculation  establishes  the  diagnosis.  If 
these  two  diseases  can  be  excluded,  vesical  hemorrhage  and  irritability 
generally  mean  tumor,  especially  if  the  hemorrhage  occurs  spon- 
taneously and  is  abundant,  and  there  is  no  other  evidence  of  bladder 
or  prostatic  disease.  A  searcher  may  detect  the  presence  of  a  hard, 
infiltrating,  cancerous  tumor,  but  it  rarely  enables  the  surgeon  to 
appreciate  the  presence  of  a  villous  tumor,  except  by  provoking 
hemorrhage. 

Tumors  and  large  stones  may  sometimes  be  palpated  by  one  finger 
in  the  rectum  or  vagina  and  the  fingers  of  the  other  hand  placed 
above  the  pubis.  Of  all  diagnostic  means  at  our  disposal,  the  cysto- 
scope  is  the  most  valuable  in  determining  early  the  presence  of  tumor 
of  the  bladder,  and  should  be  employed  as  soon  as  a  new  growth  is 
suspected,  before  the  presence  of  constant  hemorrhage  renders  its  use 
impossible.  By  its  use,  villous  tumors  generally  may  be  recognized 
by  the  presence  of  the  long,  slender  processes  which  float  about  in  the 
fluid,  and  by  the  absence  of  infiltration  of  the  bladder  wall  and  ulcera- 
tion. Cancerous  growths  are  generally  bulky,  nodular,  with  a  sur- 
rounding infiltration  of  the  bladder  wall.  They  often  present  a  ragged, 
ulcerated  surface. 

Prognosis. — The  chances  of  a  radical  and  permanent  cure  in  an 
adult  suffering  from  a  tumor  of  the  bladder  are  not  large.  Watson 
has  shown  that  the  late  results  are  so  unfavorable,  both  in  benign 
and  malignant  tumors,  that  something  far  more  radical  in  operative 
technic  must  be  employed  if  any  progress  is  to  be  expected. 

Treatment. — Small  benign  growths  sometimes  ma}'  be  successfully 
removed  by  snaring  through  the  operative  cystoscope  or  cauterized 
through  the  cystoscope  with  the  galvanocautery  or  high  frequency 
current.  As  a  rule  suprapubic  cystotomy  should  be  performed  for 
the  purposes  of  exploration  (see  Suprapubic  Lithotomy,  page  661). 


rUUOHS  OF   THE  BLADDER 


CI  17 


If  the  tumor  is  found  to  be  benign,  it  may  be  removed  by  scissors, 
cutting  forceps,  or  by  the  hot  or  cold  snare.  The  surrounding  mucous 
membrane  should  also  be  removed  and  the  resulting  wound  united 
with  previously  introduced  sutures  of  chromicized  catgut  (Figs.  309, 
310,  311).  If  the  growth  is  found  to  be  malignant  in  character  and 
does  not  involve  the  ureteral  orifices  or  trigone,  it  can  be  radically 
removed  by  excising  a  portion  of  the  bladder  wall.  This  is  best 
accomplished  by  the  method  suggested  by  Schmidt.  He  advises  a 
median  suprapubic  incision,  exposure  of  the  extraperitoneal  portion 
of  the  bladder,  and  stripping  the  peritoneum  from  the  posterior  and 


Fig.  309.- — Exposure  of  papilloma  of  bladder.     (Schmidt.) 


lateral  surfaces.  The  bladder  is  then  drawn  to  one  side  or  the  other 
and  the  diseased  area  mapped  out  by  intra-  and  extravesical  palpation. 
The  entire  diseased  area,  with  a  generous  margin  of  healthy  bladder 
wall,  is  then  excised  and  the  resulting  wound  closed  by  two  or  more 
layers  of  sutures. 

When  the  growth  involves  the  ureteric  orifice  the  ureter  is  divided 
close  to  the  bladder  and,  after  removal  of  the  diseased  area,  implanted 
in  the  upper  angle  of  the  bladder  wound  (Fig.  312). 

Where  the  disease  is  more  extensive,  especially  if  both  ureteral 
orifices    are    involved,   total    cystectomy  ma}'   be    performed   with 


668  DISEASES  OF   THE  BLADDER  AND    URETHRA 


Fig.  310. — Sutures  in  place.    (Schmidt.) 


Fig.  311. — Appearance  after  removal  of  growth  and  closure  of  wound.     (Schmidt.) 


TUMORS  <>F  THE  HLADDKH 


669 


ligation  of  both  ureters  near  the  kidney,  and  double  nephrostomy. 
In  fact,  Watson  has  suggested  this  operation  for  all  eases  of  malignant 

growth  of  the  bladder  and  for  all  eases  of  benign  growth  which  have 
recurred  after  primary  removal.  When  this  operation  has  been 
performed  the  patients  can  be  kept  fairly  dry  by  the  use  of  Watson's 
lumbar  drainage  tube  and  urinal  (Fig.  313). 


Fig.  312. — Excision  of  the  bladder  for  new  growth.     (Schmidt.) 


In  some  cases  of  malignant  growth  of  the  bladder,  especially  when 
arising  from  the  prostate,  the  best  approach  is  gained  by  a  median 
intraperitoneal  section  of  the  organ,  the  patient  being  in  the  Trendelen- 
burg position.  This  allows  ready  access  to  the  prostate  and  trigone 
and  renders  easy  the  removal  of  any  amount  of  bladder  tissue  in  this 
region.  Wlien  complete  removal  is  impossible,  suprapubic  or  perineal 
drainage  is  indicated  as  a  palliative  measure. 

Recent  experience  tends  to  demonstrate  that  most  small  benign 


670 


DISEASES  OF   THE  BLADDER  AND   URETHRA 


growths  and  some  malignant  neoplasms  may  be  treated  with  success 
by  the-  use  of  the  high-frequency  current  through  the  operating 
eystoscope. 


Fig.  313. — Watson's  Lumbar  drainage  apparatus.     (Watson  and  Cunningham,) 


FUNCTIONAL  AFFECTIONS  OF  THE  BLADDER. 

Retention  of  Urine. — While  this  is  often  a  symptom  of  some  definite 
lesion,  as  stricture  of  the  urethra,  hypertrophy  of  the  prostate,  the 
impaction  of  a  calculus,  periurethral  or  prostatic  abscess,  it  not  infre- 
quently occurs  as  a  functional  disorder  following  a  surgical  operation, 
or  be  due  to  a  temporary  overstrain  of  the  bladder,  to  fright,  to 
embarrassment,  or  to  some  other  purely  mental  disturbance. 

As  in  other  forms  of  retention,  the  symptoms  are  an  urgent  desire 
to  urinate,  pain  in  the  hypogastric  region,  and  the  presence  of  a 
tumor  formed  by  the  distended  bladder  in  the  median  line  just  above 
the  pubes. 

In  the  absence  of  any  pathologic  obstruction,  urinary  retention 
should  be  relieved  by  catheterization.  It  must  be  remembered, 
however,  that  during  an  acute  or  chronic  retention  the  bladder  is 


FUNCTIONAL   AFFECTIONS  OF  THE  BLADDER  671 

particularly  susceptible  to  infection,  and  the  same  precautions  should 
be  taken  as  in  the  relief  of  retention  due  to  prostatic  hypertrophy, 
described  on  page  713. 

Paralysis  of  the  Bladder.— Paralysis  of  the  bladder  may  occur  as  a 
result  of  spinal  trauma  and  other  pathologic  conditions  of  the  brain  and 
cord.  Incomplete  paralysis,  often  resulting  in  irregular  attacks  of 
retention  of  urine  necessitating  the  use  of  the  catheter,  is  frequently 
associated  with  locomotor  ataxia.  The  symptoms  of  paralysis  of  the 
bladder  are  retention  and  overflow.  The  urine  collects  in  the  bladder 
until  it  is  distended  to  itr  fullest  capacity,  after  which  it  dribbles 
away  through  the  urethra,  producing  a  condition  spoken  of  as  incon- 
tinence from  overflow.  The  treatment  should  be  by  regular  aseptic 
catheterization. 

Atony  of  the  Bladder. — Atony  of  the  bladder  is  a  condition  of 
paresis  of  the  detrusor  muscle,  caused  generally  by  obstructive  or 
inflammatory  disease  of  the  prostate  or  urethra,  or  as  a  result  of  tem- 
porary overstrain  of  the  bladder  from  enforced  voluntary  retention. 
The  bladder-muscle  is  not  paralyzed  but  weakened.  The  bladder  is 
able  to  expel  a  part  of  the  contained  urine,  but  contraction  is  incom- 
plete, and  a  certain  amount  of  urine  is  constantly  present  in  the 
viscus  which  cannot  be  expelled  by  voluntary  effort.  The  amount  of 
the  residual  urine  gradually  increases  until  there  may  be  great  disten- 
tion and  overflow.  The  treatment  should  be  by  regular  aseptic 
catheterization,  which  will  be  spoken  of  more  fully  under  Prostatic 
Hypertrophy.  It  is  important  whenever  possible  to  discover  and 
remove  the  cause. 

Incontinence  of  Urine. — Incontinence  of  urine,  due  to  a  lack  of 
voluntary  control  over  the  sphincter  muscle,  may  result  from  some 
pathologic  condition  of  the  spinal  cord,  from  some  mechanical  injury 
to  the  neck  of  the  bladder,  or  it  may  be  of  purely  nervous  origin.  In 
this  condition  urine  constantly  flows  from  the  bladder,  keeping  the 
clothing  wet  and  the  parts  irritated  or  excoriated.  This  true  incon- 
tinence should  not  be  confounded  with  the  false  incontinence  from 
overflow  seen  in  overdistention  of  the  bladder. 

Nocturnal  Incontinence  of  Children. — This  condition,  unfortunately 
quite  common  among  modern  children,  is  a  neurosis  which  is  character- 
ized by  an  increased  irritability  of  the  vesical  neck,  resulting  in  the 
spasmodic  expulsion  of  urine  during  sleep.  The  condition  is  a  surgical 
one,  only  in  that  it  may  be  the  result  of  some  local  irritation,  as 
phimosis,  calculus,  or  some  irritating  lesion  of  the  rectum. 

Painful  Neuroses. — Painful  neuroses  of  the  bladder  are  occasionally 
encountered  in  adults,  especially  in  hysteric  women.  These  conditions 
are  characterized  by  frequent  and  painful  urination,  retention  or 
incontinence,  the  sensation  of  a  foreign  body  in  the  urethra  or  bladder, 
great  bodily  weakness  following  urination,  and  often  an  urgent  desire 
to  urinate  as  soon  as  the  patient  is  placed  in  a  position  where  urination 
is  impossible.     The  condition  is  of  purely  medical  interest,  but  is 


672  DISEASES  OF   THE  BLADDER  AND   URETHRA 

mentioned  here  for  the  reason  that  in  its  graver  forms  the  neurosis 
often  simulates  some  important  surgical  lesion.  As  a  rule,  these 
conditions  are  characterized  by  the  fact  that  the  symptoms  are  not 
constant;  that  they  frequently  vary  from  day  to  day;  that  polyuria 
is  generally  present,  and  that  they  are  often  relieved  by  suggestive 
therapeutics. 

Treatment. — In  all  of  these  nervous  disorders  of  the  bladder  the 
treatment  should  consist  in  the  removal  of  the  cause,  if  that  is  pos- 
sible. If  not,  regular  aseptic  catheterization  when  retention  exists, 
and  the  wearing  of  a  suitable  urinal  when  incontinence  is  present. 

Pneumaturia. — It  occasionally  happens  that  air  is  passed  from  the 
bladder  with  the  urine.  This  phenomenon  is  due  either  to  the  occur- 
rence of  a  fistulous  tract  between  the  alimentary  canal  and  some  part 
of  the  urinary  tract  or,  as  suggested  by  BeVan,  to  infection  by  some 
gas-producing  organism,  especially  by  the  action  of  B.  coli  communis 
on  a  urine  containing  sugar.  In  the  great  majority  of  cases  the  cause  is 
a  fistula,  and  is  the  result  of  the  rupture  of  an  appendicular  abscess 
into  the  bladder.  In  other  cases  it  may  be  due  to  seminal  vesic- 
ulitis, to  diverticulitis,  or  to  ulceration  of  the  bowel  from  malig- 
nant diseases.  Trauma  occasionally  acts  as  a  causative  factor  and 
fistula3  from  the  kidney  pelvis  may  result  from  calculus,  renal  or 
perirenal  suppuration.  When  large  quantities  of  intestinal  matter 
are  discharged  into  the  bladder  cystitis  may  result.  The  treatment 
should  consist  in  accurately  locating  the  fistula,  measures  to  effect 
extravesical  closure,  and  in  cases  when  no  fistula  exists  in  careful 
bladder  washing  and  correction  of  the  bacilluria. 

MALFORMATIONS    OF    THE   URETHRA. 

Congenital  Absence  of  the  Urethra — Congenital  absence  of  the 
urethra  and  atresia  at  different  points  in  the  canal  have  occasionally 
been  reported;  also  congenital  diverticula,  or  urinary  pouches.  These 
conditions  are  exceedingly  rare,  and  for  their  consideration  the  reader 
is  referred  to  treatises  upon  genito-urinary  disease. 

Hypospadias. — Hypospadias  is  a  congenital  deformity  due  to  arrest 
of  development  or  to  an  intra-uterine  injury  which  results  in  a  more 
or  less  complete  absence  of  the  inferior  wall  of  the  urethra.  Three 
degrees  of  this  deformity  are  described:  the  glandular,  in  which  the 
urethra  opens  not  at  the  apex  of  the  glands,  but  on  its  inferior  surface 
in  the  space  usually  occupied  by  the  frenum;  the  penile,  in  which  the 
opening  is  on  the  under  surface  of  the  penis,  near  its  junction  with  the 
scrotum;  and  the  perineal,  in  which  the  external  urethral  orifice  is 
located  in  the  perineum.  In  the  last  variety  there  are  also  a  cleft  of 
the  scrotum,  a  rudimentary  penis,  and  often  a  failure  of  the  testicles 
to  descend,  creating  a  deformity  sometimes  described  as  pseudo- 
hermaphrodism. 

A  moderate  degree  of  hypospadias,  in  which  the  opening  is  situated 


MALFORMATIONS  OF   THE   URETHRA 


673 


at  or  near  the  glans  penis,  produces,  as  a  rule,  no  serious  inconvenience. 

In  the  severer  forms  the  sexual  function  is  impaired,  and  urination  is 
sometimes  rendered  difficult  through  narrowing  of  the  meatus  ami 
inability  to  project  the  stream  from  the  body. 

Treatment. — The  treatment  of  this  deformity  is  by  means  of  various 
plastic  procedures,  each  adapted  to  a  certain  form  of  the  defect.  In 
the  glandular  form  no  treatment  is  necessary.  If  the  opening  i>  situated 
between  the  glans  and  the  scrotum,  Carl  Beck  employs  the  following 
method:  The  urethral  orifice  and  about  one  inch  of  the  urethra  are 
dissected  free  from  the  corpus  spongiosum.     The  glans  penis  is  then 


Fi<;.    314. — Beck's    operation.  •    (Watson 
and  Cunningham. 


Fig.    315. — Beck's    operation, 
and  Cunningham.) 


Watson 


tunnelled  by  means  of  a  sharp,  thin-bladed  bistoury  from  the  apex 
backward  to  the  original  site  of  the  orifice.  Through  this  the  elastic 
urethra  is  drawn  and  retained  with  fine  silk  sutures  (Figs.  314  and 
315).  For  a  description  of  the  plastic  operations  for  the  severer  forms 
of  the  deformity,  the  reader  is  referred  to  works  on  operative  surgery. 
Epispadias. — Epispadias  is  a  congenital  malformation  resulting  in 
a  more  or  less  complete  absence  of  the  superior  wall  of  the  urethra. 
The  deformity  is  rarer  than  hypospadias.  When  complete,  the  con- 
dition is  associated  with  exstrophy  of  the  bladder,  absence  of  the 
symphysis  pubis,  and  a  rudimentary  penis.  Occasionally  the  external 
43 


674  DISEASES  OF  THE  BLADDER  AND   URETHRA 

urethral  orifice  is  situated  at  the  root  of  the  penis  or  on  the  upper 
surface  of  the  glans.  In  these  cases  the  glans  or  rudimentary  penis 
is  cleft  or  deeply  grooved.  Some  of  the  incomplete  forms  may  be 
remedied  or  improved  by  plastic  operations. 

INJURIES    OF    THE   URETHRA. 

Contusions  of  the  Urethra. — Contusions  of  the  urethra  may  occur  as 
a  result  of  blows  or  falls  upon  the  penis  or  perineum.  The  mucous 
membrane  may  be  swollen,  ecchymosed,  and  surrounded  by  a  blood 
clot  giving  rise  to  partial  obstruction  to  the  passage  of  urine.  Xo 
treatment  is  required  other  than  that  addressed  to  the  external  iniury. 

Wounds  of  the  Urethra. — Wounds  of  the  urethra  may  occur  from 
stab  or  gunshot  injuries,  from  glass  cuts,  and  as  a  result  of  various 
other  lacerating  traumata.  If  infected  or  severely  contused  stricture 
is  apt  to  develop.  Hemorrhage  is  often  severe  and  there  may  be 
extravasation  of  urine.  Clean-cut  longitudinal  wounds  should  be 
freely  exposed  and  united  with  fine  catgut  sutures  over  a  catheter  which 
should  be  left  in  situ  for  a  few  days;  ragged,  contused,  and  irregular 
wounds  should  be  treated  upon  the  principles  laid  down  for  the  treat- 
ment of  urethral  rupture. 

Rupture  of  the  Urethra. — Rupture  of  the  urethra  is  of  fairly  frequent 
occurrence.  It  may  be  partial,  involving  either  the  fibrous  sheath  or 
the  mucous  membrane,  or  total,  involving  sheath,  mucous  membrane 
and  corpus  spongiosum.  It  is  important  on  account  of  the  fact  that, 
if  it  is  unrecognized  or  neglected,  it  is  apt  to  be  followed  by  extrava- 
sation, gangrene,  sepsis,  and  death;  also  because  it  is  frequently  the 
cause  of  a  subsequent  stricture. 

The  injury  occurs  with  greatest  frequency  in  theperineal  region  involv- 
ing the  bulbous  portion  of  the  canal,  and  is  caused  by  blows,  kicks,  or 
falling  astride  a  beam  or  other  hard  substance.  It  may  occur  in  the 
penile  urethra  from  any  injury  which  forcibly  drives  the  penis  upward 
against  the  pubic  bone,  especially  if  received  during  erection.  It  may 
involve  the  membranous  urethra  as  a  complication  of  pelvic  fracture 
but  is  rare  in  the  prostatic  portion  of  the  canal.  As  a  rule,  it  is  accom- 
panied by  more  or  less  contusion  of  the  overlying  soft  parts,  but  the 
injury  to  the  urethra  is  usually  caused  by  its  being  pushed  violently 
against  the  pubic  bone.  The  wound  is  generally  a  lacerated  one, 
and  may  completely  divide  the  canal.  When  the  patient  attempts  to 
urinate,  the  urine  is  forced  out  into  the  surrounding  tissues,  producing 
more  or  less  extensive  extravasation,  which,  if  unrelieved,  results  in 
sloughing  of  the  parts,  cellulitis,  and  abscess. 

Symptoms. — The  symptoms  of  rupture  of  the  urethra  are  localized 
pain,  hemorrhage,  and  retention.  The  pain  is  moderate  in  degree  at 
first,  but  often  is  greatly  increased  after  efforts  at  micturition,  which 
give  rise  to  increased  hemorrhage  and  extravasation  of  urine  into  the 
surrounding  tissues.    Hemorrhage  may  immediately  follow  the  injury, 


INJURIES  OF  THE   URETHRA  675 

or  it  may  appear  only  during  efforts  at  urination.  Retention  may  be 
complete,  or  any  amount  of  urine  may  be  passed.  Absolute  retention 
generally  means  extensive  laceration  or  a  complete  transverse  rupture 
of  the  canal.  Extravasation  into  the  anterior  perineal  compartment, 
between  the  deep  perineal  fascia  and  anterio'r  layer  of  the  triangular 
ligament,  gives  rise  to  a  perineal  swelling  which  lies  between  the  rami 
of  the  pubis  and  above  a  transverse  line  connecting  the  two  tuberosities 
of  the  ischium.  If  the  extravasation  is  large,  the  tissues  of  the  scrotum 
are  infiltrated  and  the  swelling  appears  in  the  abdominal  wall  above 
the  pubis.  If  the  extravasation  occurs  between  the  two  layers  of 
the  triangular  ligament,  the  deep  perineal  compartment,  it  appears 
as  a  deep  triangular  induration  which  is  limited  in  extent  until  it 
ruptures  into  the  ischiorectal  fossa  or  anterior  perineal  space.  Extrav- 
asations behind  the  deep  layer  of  the  triangular  ligament  (from  the 
prostatic  urethra)  may  burrow  above  the  levator  ani  muscle  or  rupture 
downward  into  the  ischiorectal  fossa.  Abscess,  sloughing,  and  exten- 
sive loss  of  tissue  result  unless  the  extravasation  is  speedily  relieved 
by  free  incisions. 

Treatment. — The  first  indication  is  to  relieve  the  retention  of  urine 
when  this  is  present.  This  should  be  accomplished  by  the  introduction 
of  a  catheter.  It  will  generally  be  found  that  a  solid  silver  instru- 
ment or  the  gum-elastic  coude  catheter  will  be  most  serviceable; 
the  beak  of  the  instrument  should  continually  hug  the  roof  of  the 
canal  during  its  introduction,  as  this  is  the  part  that  is  least  likely  to 
be  injured  by  the  trauma.  Prolonged  efforts  at  catheterization  should 
not  be  made.  If  a  catheter  slips  easily  into  the  bladder  it  may  be  tied 
in  situ,  left  in  place  for  a  few  days  and  the  canal  subsequently  dilated 
with  sounds.  If  the  instrument  does  not  readily  pass,  the  retention,  if 
urgent,  may  be  relieved  by  aspiration  while  the  patient  is  being  pre- 
pared for  operation.  In  complete  perineal  rupture  of  the  urethra  an 
external  incision  may  be  made  down  to  the  point  of  rupture  and  the 
divided  ends  of  the  canal  sutured  with  fine  catgut,  the  wound  closed, 
and  a  catheter  passed  to  the  bladder  and  tied  in.  This  theoretically 
ideal  method  almost  never  succeeds.  The  method  usually  adopted  is 
to  remove  all  bruised  and  necrotic  shreds  of  tissue,  introduce  a  No. 
30  F.  perineal  drainage  tube  into  the  bladder  through  the  perineal 
wound,  and  secure  it  in  place  by  a  suture  and  packing.  As  soon  as 
the  wound  begins  to  granulate  the  tube  can  be  removed  and  full- 
sized  sounds  passed  every  second  or  third  day  until  the  perineal 
wound  has  healed.  If  there  has  been  a  complete  rupture,  or  if  there 
is  much  loss  of  urethral  tissue,  sounds  should  be  employed  at  inter- 
vals throughout  life.  It  sometimes  happens  after  severe  injuries  that 
the  proximal  end  of  the  urethra  cannot  be  found  in  the  perineal  wound. 
Under  these  circumstances  retrograde  catheterization  through  a 
suprapubic  opening  may  be  necessary.  In  severe  lacerations  of  the 
penile  urethra,  external  perineal  urethrotomy  with  bladder  drainage  is 
indicated,  with  the  use  of  a  full-sized  rubber  catheter  passed  from  the 


676  DISEASES  OF   THE  BLADDER  AND    URETHRA 

meatus  to  the  perineal  wound  and  retained  in  plaee  until  granulation 
of  the  wound  is  well  advanced.  This  should  be  followed  by  the  regular 
use  of  sounds  for  a  long  period. 

DISEASES    OF    THE   URETHRA. 

Acute  Urethritis. — Acute  urethritis  is  an  inflammation  of  the  urethral 
mucous  membrane,  characterized  by  the  presence  of  a  purulent  dis- 
charge and  painful  urination.  Although  acute  urethritis  may  be 
occasioned  by  trauma,  gout,  rheumatism,  typhoid  fever,  and  a  variety 
of  other  less  virulent  infections,  in  99  of  every  100  cases  the  disease 
is  due  to  infection  of  the  urethral  mucous  membrane  by  the  gonococcus, 
and  is  acquired  by  sexual  contact. 

The  gonococcus  is  a  kidney-bean-shaped  diplococcus  usually  occur- 
ring in  fours  or  multiples  of  four.  It  is  found  in  the  epithelial  cells, 
leukocytes,  and  free  in  the  discharges.  It  stains  readily  with  aniline 
dyes  and  is  decolorized  by  Gram's  method.  They  usually  may  be 
found  in  large  numbers  in  the  pus  of  an  early  case,  and  their  presence 
and  identification  is  of  the  greatest  diagnostic  importance.  The 
gonococcus  is  difficult  of  cultivation  and  frequently  assumes  atypical 
forms  when  grown  upon  laboratory  media. 

When  deposited  upon  the  mucous  membrane  of  the  meatus  they 
soon  spread  to  the  pendulous  portion  of  the  urethra  and  pass  through 
and  between  the  epithelial  cells  into  the  submucous  connective  tissue. 
They  proliferate  in  large  numbers  about  the  ducts  of  the  excretory 
glands  and  lacunae  from  whence  it  is  often  difficult  to  dislodge  them. 

Symptoms. — After  a  period  of  incubation  which  varies  from  one 
to  fourteen  days  the  patient  will  experience  an  itching  or  burning 
sensation  about  the  meatus,  with  slight  pain  on  urination.  If  exam- 
ined at  this  time,  the  lips  of  the  meatus  will  be  found  to  be  reddened 
and  edematous,  and  a  drop  of  cloudy  mucus  can  be  expressed  from 
the  urethra.  These  symptoms  rapidly  increase  in  severity,  the  dis- 
charge becomes  more  abundant,  and  the  pain  on  urination  more 
acute.  The  penis  is  swollen,  the  prepuce  becomes  edematous,  the 
glans  fiery  red  and  tender  to  the  touch.  Erections  occur,  chiefly  at 
night,  and  are  often  exquisitely  painful.  The  discharge  becomes 
thick  and  creamy,  and  the  pain  on  urination  intense.  In  uncom- 
plicated and  untreated  cases  the  height  of  the  disease  is  reached  about 
the  tenth  or  twelfth  day.  From  this  time  it  may  continue  without 
improvement  for  from  four  to  six  weeks.  It  then  gradually  subsides, 
and,  after  a  muriber  of  weeks,  the  discharge  may  lose  its  purulent 
character  and  become  scanty  and  watery.  In  a  large  number  of  cases 
symptoms  of  posterior  urethritis  appear  early  in  the  disease,  generally 
as  a  result  of  some  unusual  bodily  exertion,  sexual  excitement,  or 
alcoholic  stimulation.  These  are  frequent  micturition,  vesical  tenes- 
mus, and  sometimes  the  passage  of  blood  with  the  last  drop  of  urine 
expressed.     Of  the  other  complications  which  are  likely  to  occur  in 


DISEASES  OF  THE   URETHRA  677 

cases  of  acute  urethritis,  epididymitis  is  the  most  frequent:  cystitis, 
prostatitis,  seminal  vesiculitis,  pyelitis,  gonorrheal  rheumatism,  and 
genera]  sepsis  arc  occasionally  encountered,  and  will  be  considered  in 
separate  sections. 

Diagnosis. — The  occurrence  of  an  acute  purulent  discharge  accom- 
panied by  painful  urination  and  chordee  in  a  previously  healthy 
individual  would  be  sufficient  to  render  the  diagnosis  of  a  gonorrheal 
infection  almost  certain.  The  finding  of  the  gonococcus  in  the  secre- 
tion would  remove  all  doubt.  The  non-gonorrhea  1  infections  of  the 
urethra  are,  as  a  rule,  much  less  severe  and  are  short-lived.  If  the  two 
glass  urine  test  is  applied,  the  presence  of  pus  in  the  second  glass 
indicates  posterior  urethritis. 

Prognosis. — It  is  possible  that  an  untreated  case  of  gonorrheal 
urethritis  may  recover;  but  recovery  under  these  circumstances  must 
be  exceedingly  rare,  for  even  under  the  most  approved  methods  of 
treatment  a  fairly  large  proportion  of  cases  never  fully  recover.  The 
disease  is  apt  to  remain  in  the  glands  and  follicles  of  the  urethra  and 
prostate,  as  well  as  in  the  ejaculatory  ducts  and  seminal  vesicles,  for 
a  long  period  of  time.  In  these  situations  gonococci  develop,  and 
cause  a  small  purulent  secretion  which  from  time  to  time  is  poured 
out  into  the  urethral  canal  and  may  reinfect  its  mucous  surface,  pro- 
ducing the  frequent  acute  attacks  which  certain  individuals  experience 
as  a  result  of  coitus,  sexual  excitement,  or  the  excessive  use  of  alcohol. 
Under  appropriate  treatment  the  disease  may  be  expected  to  subside 
and  complete  recovery  to  take  place  in  from  four  to  six  weeks.  Cessa- 
tion of  discharge  may  often  be  effected  in  from  three  to  ten  days,  but 
much  more  treatment  is  required  before  the  patient  can  be  said  to  be 
cured. 

Treatment. — Patients  undergoing  treatment  for  an  acute  urethritis 
should  abstain  from  all  alcoholic  drinks,  excessive  bodily  exertion, 
sexual  excitement,  and  highly  seasoned  food.  They  should  drink 
copiously  of  pure  water,  lemonade,  or  milk  and  vichy.  Copaiba, 
sandal-wood  oil,  and  cubebs,  when  given  in  sufficiently  large  doses, 
greatly  diminish  the  amount  of  discharge  and  ardor  urina?,  but  do  not 
cure.  They  are  often  useful  as  auxiliary  measures  when  the  symptoms 
are  too  acute  to  permit  the  use  of  more  effective  local  treatment. 

Irrigation  of  the  urethra  with  mild  solutions  of  mercuric  chloride 
or  potassium  permanganate  has  long  been  a  popular  method  of  treat- 
ing the  disease.  The  urethra  should  first  be  cleared  of  pus  by  urina- 
tion, after  which  from  1  pint  to  1  quart  of  a  warm  bichloride  solution 
(1  to  30,000)  or  permanganate  (1  to  8000)  should  be  allowed  to  pass 
through  the  anterior  urethra  by  means  of  the  Janet  or  Valentine 
irrigating  apparatus  (Fig.  316).  The  strength  of  these  solutions  may 
be  gradually  increased  as  the  symptoms  improve.  This  method,  how- 
ever, has  of  late  been  superseded  by  the  use  of  solutions  of  the  newer 
silver  salts. 

Argonin,   protargol,    argyrol,    and   novargan   have   been   the   ones 


678 


DISEASES  OF  THE  BLADDER  AND   URETHRA 


most  frequently  employed.  Swinburne,  who  has  thoroughly  tested 
all  of  these  agents,  recommends  argyrol  in  10  per  cent,  solution  or 
novargan  in  a  2  per  cent,  strength.  These  are 
injected  into  the  urethra  after  urination,  and 
allowed  to  remain  one  minute.  By  this 
method  early  cases  often  can  be  aborted,  and 
practically  all  can  be  controlled. 

For  the  treatment  of  posterior  urethritis, 
the  use  of  these  solutions  in  the  deep  urethra 
by  means  of  the  Ultzmann  or  Keyes  deep 
urethral  syringe  (Fig.  317)  will  be  found 
effective.  The  instillations  should  be  made 
not  oftener  than  once  a  day;  about  10  drops 
should  be  used,  and  the  strength  of  the  solu- 
tion should  be  somewhat  stronger  than  that 
used  in  the  anterior  portion  of  the  canal.  Irri- 
gation of  the  entire  urethra  and  bladder  from 
the  meatus  by  hydrostatic  pressure  by  means 
of  the  Janet  or  Valentine  apparatus  is  to  be 
recommended  when  posterior  urethritis  is 
present,  but  only  weak  solutions  of  silver 
nitrate  or  potassium  permanganate  should 
be  employed.  After  the  discharge  has  lost  its 
purulent  character,  and  after  the  gonococci 
have  disappeared  from  the  thin,  watery  secre- 
tion, irrigations  should  be  suspended  and  the 
injection  of  some  astringent  solution,  as  zinc 
sulphocarbolate,  lead  acetate,  or  bismuth 
suspended  in  glycerin  and  water,  advised. 
These  injections  should  be  repeated  several 
times  a  day,  always  after  urination.  If  the 
discharge  does  not  readily  disappear  under 
this  treatment,  the  urethra  should  be  ex- 
amined by  the  urethroscope  (Fig.  318)  for 
inflamed  follicles  or  granular  patches  in  the 
anterior  urethra,  or  by  the  Swinburne  pos- 
terior urethroscope  when  the  lesions  are 
situated  in  the  deeper  portions  of  the  canal. 
These  when  present  may  be  treated  by  direct 
applications  of  strong  silver  nitrate  solutions 
through  the  endoscopic  tube.  The  use  of  steel 
sounds  two  or  three  times  a  week  will  often  be 
found  useful  in  this  stage  of  the  disease.  The 
patient  can  be  pronounced  cured  only  when  no 
discharge  exists,  and  when  the  urine,  after  being  retained  for  six  hours, 
shows  no  free  pus  or  tripper  faden  containing  pus  or  gonococci.  The  pros- 
tate and  its  expressed  material  should  also  be  carefully  examined. 


I     2    3 


Fig.    316. — Valentine 
gating  apparatus 


DISEASES  OF  THE   URETHRA 


679 


Chronic  Urethritis. — It  frequently  happens,  even  after  the  most 
careful  treatment,  that  acute  urethritis  is  followed  by  a  chronic  con- 
dition characterized  by  the  presence  of  a  more  or  less  constant  thin 
mucopurulent  discharge  {gleet),  without  pain  or  other  discomfort,  and 
by  a  frequent  return  of  the  acute  symptoms  of  the  disease  as  a  result 
of  sexual  excitement  or  alcoholic  indulgence.    These  recurrent  acute 


Fig.  317. — Keyes'  deep  urethral  syringe. 

attacks  may  closely  resemble  a  fresh  infection,  and  require  the  same 
treatment.  Frequently  there  is  no  visible  discharge  and  the  patient 
believes  himself  to  be  well,  and  the  only  sign  of  the  disease  may  be 
the  presence  in  the  urine  of  small,  thread-like  bodies  (tripper  faden) 
which  represent  the  minute  purulent  secretion  which  adheres  to  a 
granular  patch  or  the  contents  of  an  inflamed  gland  or  follicle  of  the 
urethral  mucous  membrane.    This  condition  is  frequently  associated 


:*w,lu>..i-:.f..a3Jk^j 


Fig.  318. — Electric  urethroscope. 

with  stricture,  chronic  seminal  vesiculitis,  or  follicular  prostatitis,  and 
requires  long-continued  treatment  with  sounds,  deep  instillations,  and 
local  applications. 

The  condition  is  important  chiefly  for  the  reason  that  the  urethral 
secretions  in  these  chronic  cases  are  often  highly  contagious,  a  fact 
formerly  not  generally  recognized  by  the  profession. 


680  DISEASES  OF   THE  BLADDER  AND   URETHRA 

At  the  end  of  the  fifth  or  sixth  week  of  the  disease  the  presence  of 
a  specific  antibody  can  be  demonstrated  in  the  blood  of  a  large  pro- 
portion of  cases  by  a  complement-fixation  test  similar  in  its  mode  of 
action  to  the  Wassermann  test  for  syphilis.  In  the  chronic  cases  with 
their  complications  it  remains  positive  in  a  high  percentage  of  patients, 
and  is  of  great  assistance  in  both  diagnosis  and  treatment,  especially 
when  the  gonococcus  cannot  be  demonstrated  in  the  discharges. 

Vaccine  and  serum  therapy  in  certain  forms  of  the  disease  has 
proven  to  be  of  great  value.  In  the  very  acute  stage  there  is  little  or 
no  absorption  from  the  anterior  urethra,  the  complement-fixation  test 
is  negative,  and  it  is  not  until  the  disease  has  invaded  the  posterior 
urethra  that  complications  are  apt  to  arise.  It  may  be  used  with 
advantage  in  the  severer  complications  at  this  stage  such  as  epididy- 
mitis, prostatitis,  pyelitis,  etc.;  also  at  any  stage  if  there  is  systemic 
invasion  with  gonorrheal  bacteriemia;  here  the  serum  is  indicated,  for 
a  rapid  passive  immunity  is  necessary. 

In  some  of  the  chronic  phases  of  the  disease  vaccines  may  be  helpful. 
Perhaps  the  most  favorable  results  are  obtained  in  the  gonorrheal 
affections  of  serous  membranes,  synovitis,  tenosynovitis,  etc.,  espe- 
cially in  the  acute  stage.  In  these  cases  vaccine  should  be  em- 
ployed. It  should  be  remembered  that  at  this  time  there  may  be, 
and  often  is,  a  mixed  infection,  and  that  the  best  results  are  often 
obtained  with  mixed  vaccines. 

The  serum  should  be  administered  in  small  doses  repeated  fre- 
quently (not  at  long  intervals  on  account  of  the  danger  of  producing 
anaphylaxis. 

The  vaccine  is  best  given  in  gradually  increasing  doses  at  intervals  of 
from  two  to  three  days.  When  possible  it  should  be  autogenous  and, 
if  indicated,  mixed  with  the  vaccines  of  the  secondary  organisms 
present.  The  complement-fixation  test  furnishes  a  good  indication 
for  vaccine  therapy  but  even  when  this  is  negative  its  use  may  be 
indicated  in  difficult  cases. 

Stricture  of  the  Urethra. — Stricture  of  the  urethra  is  an  abnormal 
narrowing  of  the  canal  due  to  cicatricial  contraction  following  gonor- 
rhea, ulceration,  periurethral  inflammation,  or  trauma.  The  cicatrix 
may  completely  surround  the  canal,  or  it  may  be  limited  to  a  portion 
only  of  its  circumference.  This  condition  is  frequently  spoken  of  as 
organic  stricture,  to  distinguish  it  from  spasmodic  stricture,  a  con- 
dition which  may  produce  similar  symptoms,  but  is  due  simply  to  a 
reflex  contraction  of  the  urethral  muscles. 

Strictures  following  gonorrhea  may  occur  at  any  point  in  the  urethra 
anterior  to  the  prostate,  but  are  most  frequent  in  the  region  of  the 
bulb  or  near  the  meatus.  They  are  usually  mutiple.  The}'  begin  as 
round-cell  infiltrations  of  the  mucous  membrane  and  submucous 
tissue,  which  are  easily  detected  in  the  earlier  stages  by  the  bulbous 
bougie  (Fig.  319)  or  urethrameter  of  Otis.  If  subjected  to  gradual 
dilatation  at  this  period,  they  frequently  become  absorbed  and  com- 


DISEASES  OF  THE  URETHRA  (is  I 

pletely  disappear.  If  neglected,  they  become  more  fibrous  in  char- 
acter and  yield  less  readily  to  the  use  of  sounds.  Strictures  occurring 
in  the  penile  urethra  rarely  contract  to  such  an  extent  as  to  cause 
retention  of  urine.  In  the  region  of  the  bull)  and  membranous  urethra, 
however,  they  are  prone  to  produce  great  narrowing  of  the  canal,  often 
converting  it  into  a  dense  fibrous  cord  tunnelled  only  by  a  narrow, 
tortuous  channel.  As  a  result  of  the  resistance  offered  by  such  a 
stricture  to  the  outward  passage  of  urine  the  urethra  behind  the 
stricture  is  dilated  and  the  bladder  hypertrophied.  There  is  often  an 
associated  cystitis.  The  mucous  follicles  and  urethral  glands  behind 
such  a  narrowing  partake  in  the  general  dilatation,  and  may  be  con- 
verted into  minute  diverticula,  which,  if  infection  be  added,  may  form 
periurethral  abscesses  which  may  or  may  not  retain  their  connection 
with  the  urethral  canal.  When  such  an  abscess  breaks  externally  a 
urinary  fistula  may  result.  If  the  stricture  becomes  too  narrow  to 
allow  the  urine  to  be  forced  through,  or,  what  is  far  more  common,  if 
a  certain  amount  of  inflammation  or  edema  develops  about  a  narrow 
but  not  impermeable  stricture,  absolute  retention  of  urine  results. 
This  quickly,  causes  extreme  distension  of  the  bladder  and  of  the 
urethra  behind  the  strictured  area,  giving  rise  to  violent  expulsive 
efforts  on  the  part  of  the  patient,  which  frequently  result  in  rupture 
of  the  urethra  and  extravasation  of  urine  into  the  tissues  of  the  peri- 
neum and  scrotum,  quickly  leading,  if  not  relieved,  to  gangrene,  abscess- 
formation,  and  grave  sepsis.  In  narrow  strictures  of  long  standing 
the  hypertrophied  muscular  fibres  of  the  bladder  may  become  sep- 
arated and  the  mucous  membrane  be  forced  between  these  muscular 
bands,  forming  diverticula  or  a  condition  described  as  a  trabecuhrfed 
bladder.  In  these  chronic  cases  more  or  less  cystitis  usually  develops 
and  the  bladder  becomes  small  and  contracted.  If  the  intravesical 
pressure  is  long  continued,  the  ureters  and  renal  pelves  may  dilate, 
giving  rise  to  single  or  double  hydronephrosis.  If  to  this  condition 
infection  is  added,  a  septic  pyelonephritis  results. 

Symptoms. — In  strictures  of  large  calibre  there  may  be  no  symptoms 
whatever,  or  there  may  be  only  the  symptoms  of  chronic  urethritis  due 
to  the  presence  of  granular  patches  behind  the  point  or  points  of  nar- 
rowing. When  the  stricture  becomes  sufficiently  narrowed  to  cause  ob- 
struction to  the  natural  flow  of  urine,  the  calls  to  urinate  may  be  more 
frequent,  and  each  act  of  micturition  is  accompanied  by  an  unusual  and 
sometimes  painful  effort.  The  stream  is  small,  twisted,  or  scattering, 
and  is  expelled  with  little  or  no  force.  Frequent  micturition  caused  by 
an  associated  chronic  prostatitis  or  cystitis  may  be  present.  There  may 
be  incontinence  of  urine  in  the  form  of  scanty  involuntary  dribbling 
after  micturition,  or  urine  may  escape  on  exertion.  Sexual  excitement, 
alcoholic  excesses,  and  severe  bodily  strain  will  frequently  cause  an 
aggravation  of  the  condition  from  congestion  of  the  parts,  and  tem- 
porary attacks  of  partial  or  complete  retention  may  occur.  These 
attacks  are  usually  associated  with  severe  cramp-like  pain  in  the  region 


682  DISEASES  OF   THE  BLADDER  AND   URETHRA 

of  the  bladder.  There  is  usually  more  or  less  shock.  Xo  urine  or  at 
most  but  a  few  drops  are  passed,  and  the  bladder  is  found  to  be  dis- 
tended. These  are  generally  relieved  by  a  hot  bath  and  mild  cathartic 
measures.  The  attacks  of  retention  gradually  increase  in  frequency 
until  finally  one  occurs  which  is  not  relieved  by  the  ordinary  methods 
of  treatment;  and  unless  surgical  measures  can  be  promptly  employed, 
extravasation  of  urine  takes  place,  followed  by  abscess,  sloughing,  and 
urinary  fistula.  Death  not  infrequently  occurs  as  a  result  of  septic 
infection  following  extravasation  of  urine  or  from  septic  pyelonephritis. 

Diagnosis. — In  a  suspected  case  of  stricture  the  following  method 
may  be  employed  to  arrive  at  a  correct  diagnosis.  The  patient  is 
instructed  first  to  pass  the  urine  into  two  glasses.  Pus  and  shreds  in 
the  first  glass,  the  second  remaining  clear,  indicate  the  presence  of  a 
urethritis  or  an  open  prostatic  abscess.  An  equal  amount  of  free  pus 
in  both  glasses  indicates  cystitis  or  pyelitis.  A  large  amount  of  pus 
in  the  first  and  a  small  amount  in  the  second  glass  indicate  posterior 
urethritis.  The  presence,  size,  and  situation  of  a  stricture  may  also 
be  determined  by  the  careful  passage  of  bulbous  bougies  beginning 
with  the  larger  sizes  until  one  is  found  which  will  pass.  A  preliminary 
meatotomy  may  have  to  be  performed.  Strictures  of  the  penile 
urethra  often  can  be  palpated  upon  the  bougie.  French  No.  28  or 
30  instrument  should  pass  easily  through  the  normal  urethra.  A 
stricture  may  often  be  accurately  located  and  examined  by  means  of 
the  urethroscope.  Care  should  be  used  in  its  introduction  to  produce 
no  unnecessary  trauma.  After  the  anterior  urethra  has  been  measured, 
an  attempt  should  be  made  to  explore  the  deep  urethra  by  introducing 
the  largest  sized  steel  sound  which  will  pass  the  anterior  portion  of 
the  canal.  If  this  is  arrested,  smaller  sizes  are  attempted  until  one 
finally  passes  to  the  bladder.  If  the  smallest  steel  sound  will  not  pass, 
an  attempt  should  be  made  with  the  smaller  gum  elastic  or  filiform 
bougies.  After  the  examination  has  been  completed  the  urethra  and 
bladder  should,  if  possible,  be  irrigated  with  a  mild  solution  of  silver 
nitrate  (1  to  10,000)  or  of  argyrol.  True  stricture  of  the  urethra  must 
be  differentiated  from  spasm  of  the  compressor  urethra?  muscle  and 
malignant  disease  of  the  prostate.  When  obstruction  is  encountered, 
especially  in  the  deep  urethra,  a  rectal  examination  should  be  made  to 
ascertain  the  condition  of  the  prostate.  Spasm  of  the  urethra  will 
vield  to  steady  gentle  pressure  with  sound  or  bougie. 

Treatment. — If  the  surgeon  is  called  upon  to  relieve  an  attack  of 
acute  retention  of  urine,  during  the  course  of  the  preliminary  examina- 
tion just  described,  a  small  bougie  or  filiform  may  be  passed  to  the 
bladder.  This  should  be  tied  in  and  left  in  place  to  serve  as  a  guide 
while  the  patient  is  being  prepared  for  operation.  If  for  anv  reason 
radical  operation  is  not  advisable  at  that  time,  the  retention  will  be 
graduallv  relieved  by  urine  passing  along  the  side  of  the  bougie.  This 
will  be  hastened  by  the  use  of  a  hot  bath  and  the  ingestion  of  hot 
diuretic  drinks.    Chloral,  grains  v-x,  every  four  hours,  is  useful  to  allay 


DISEASES  OF  THE   URETHRA  683 

muscular  spasm.  Twelve  hours  later  the  bougie  may  be  removed  and 
replaced  by  a  larger  size,  and  from  this  point  gradual  dilatation  may 
be  practised. 

Instruments  for  dilatation  are  made  of  metal  or  some  flexible 
material.  They  are  usually  calibrated  according  to  the  French  scale 
in  millimetres.  In  general  the  smaller  the  metal  instrument  the 
greater  is  the  danger  of  damaging  the  urethra.  When  indicated  they 
should  be  used  with  great  care  and  gentleness  and  only  by  those  who 
have  had  some  experience  in  urethral  instrumentation.  All  instru- 
ments should  be  sterile  and  thoroughly  lubricated.  Several  sizes  of 
the  gum-elastic,  olive-pointed  bougies  (Fig.  .320)  should  be  introduced 
each  day  until  the  stricture  is  suffieientlv  dilated  to  admit  a  No.  15 
F.  steel  sound,  after  which  these  instruments  should  be  employed. 

Dilatation  should  proceed  gradually  at  regular  intervals  until  the 
stricture  has  been  stretched  well  beyond  25  F.  Dilatation  may  be 
complicated  bv  the  production  of  a  false  passage,  and  if  this  accident 
should  occur  instrumentation  should  be  suspended  if  possible  for  a 
few  days.  Infection  may  be  avoided  by  care  in  technic.  The  passage 
of  urethral  instruments  is  often  attended  by  a  transitory  faintness, 
pallor,  and  malaise;  sometimes  by  actual  syncope.  These  symptoms 
usually  pass  off  in  a  few  minutes.  The  majoritv  of  cases  should  be 
kept  under  observation  for  several  years  and  the  occasional  passage  of 
a  sound  will  prevent  recurrence.  It  is  surprising  how  frequently  an 
obstinate  gleet  will  disappear  after  dilatation,  in  fact  insufficient 
drainage  frequently  determines  the  persistence  of  a  urethral  discharge. 

Cocaine  or  its  derivatives  if  used  as  a  local  anesthetic  must  be 
handled  with  great  care.  Its  effect  upon  an  intact  mucous  membrane 
is  local  and  large  amounts  may  be  injected  without  producing  any 
general  symptoms.  In  cases  where  ulceration  is  present  or  especially 
where  a  false  passage  has  been  created  by  previous  unsuccessful  instru- 
mentation (a  not  infrequent  complication),  absorption  is  rapid  and 
alarming  toxic  symptoms  may  follow  the  injection  of  comparatively 
small  quantities. 

In  cases  in  which  the  distension  of  the  bladder  is  great  and  there  is 
danger  of  extravasation,  the  use  of  the  Gouley  tunnelled  sound  (Fig. 
321)  or  catheter  (Fig.  322)  over  the  filiform  may  be  necessary  to 
relieve  the  retention  quickly. 

In  case  no  bougie  can  be  passed,  the  patient  should  be  etherized 
and  placed  in  the  lithotomy  position,  and  after  the  usual  prepara- 
tion of  the  parts  a  sound  should  be  introduced  to  the  strictured 
area  if  this  is  located  in  the  perineal  region,  and  held  firmly  against 
the  stricture  by  an  assistant.  A  longitudinal  incision  is  then  made 
in  the  median  line  of  the  perineum,  and  the  various  tissues 
divided  until  the  urethra  is  reached;  this  is  then  opened  on  the 
point  of  the  sound,  and  the  edges  of  the  urethral  wound  held  apart 
by  two  silk  sutures.  An  attempt  is  then  made  to  pass  a  fine  probe 
director  to  the  bladder.     If  there  are  no  false  passages  and  the 


684 


DISEASES  OF   THE  BLADDER  AND    URETHRA 


case  has  not  been  subjected  to  harsh  instrumentation,  the  posterior 
urethral  opening  can  generally  be  found  at  the  apex  of  a  cone  made 


Fig.  319.— Bul- 
bous bougie. 


Fig.  320.— Olive- 
pointed  bougie. 


Fig.  321.— Gouley 
tunnelled  sound. 


Fig.  322.— 
Gouley  catheter. 


by  drawing  outward  the  urethral  margins  by  the  silk  sutures.  It 
occasionally  happens  that  a  very  considerable  search  is  made  before 
finding  the  posterior  opening,  and  a  careful  dissection  of  the  perineum 


DISEASES  OF  THE   URETHRA  685 

may  be  necessary.  When  found,  the  posterior  urethra  should  be 
dilated  with  dressing-forceps  passed  along  the  groove  of  the  director, 
or  by  the  finger.  A  full-sized  sound  is  next  passed  from  the  meatus  to 
the  bladder  to  insure  the  patency  of  the  entire  canal,  after  which  a  No. 
MO  or  32  F.  rubber  perineal  drainage  tube  should  be  passed  into  the 
bladder  through  the  perineal  wound  and  secured  by  a  single  suture. 
The  wound  should  then  be  packed  around  the  tube  and  a  T-bandage 
applied.  When  the  patient  is  placed  in  bed  the  end  of  the  drainage 
tube  should  be  connected  with  one  leading  to  a  large  bottle  or  reser- 
voir placed  under  the  bed,  and  containing  a  solution  of  mercuric 
chloride.  Frequent  irrigations  of  the  bladder  with  a  bland  sterile 
solution  should  be  practised. 

If  no  posterior  opening  can  be  found,  two  methods  are  open  to  the 
surgeon:  One  of  these  is  known  as  Cock's  operation,  which  consists 
in  placing  the  forefinger  of  the  left  hand  in  the  rectum  and  finding 
the  apex  of  the  prostate,  then  with  the  right  hand  passing  a  thin- 
bladed  knife  through  the  perineal  tissues  backward  and  upward  exactly 
in  the  median  line  until  the  dilated  posterior  urethral  pouch  is  opened 
just  above  the  tip  of  the  finger  in  the  rectum.  The  cicatricial  tissue 
which  generally  is  found  to  intervene  between  the  anterior  and  poste- 
rior portions  of  the  urethra  is  then  dissected  away,  a  full-sized  sound 
passed  from  the  meatus  to  the  bladder,  and  the  bladder  drained  with 
a  No.  32  F.  rubber  tube  as  described  above.  The  other  alternative  is 
to  open  the  bladder  from  above  (suprapubic  cvstotomy),  and  to  pass 
a  sound,  catheter,  or  bougie  outward  through  the  internal  urethral 
orifice  until  it  bulges  the  tissues  in  the  perineal  wound.  It  may  then 
be  cut  down  upon  and  the  case  treated  as  in  Cock's  operation  after 
partial  or  complete  suture  of  the  suprapubic  wound.  In  cases  of 
extreme  urgency  it  may  be  necessary  to  relieve  the  acute  retention 
before  the  patient  can  be  prepared  for  operation.  Under  these  cir- 
cumstances aspiration  of  the  bladder  above  the  pubes  may  be  practised. 
While  this  procedure  is  only  for  temporary  relief,  it  may  be  repeated 
two  or  three  times  if  necessary  before  more  radical  measures  are 
undertaken.  The  writer  occasionally  has  seen  voluntary  urination 
restored  after  aspiration,  presumably  from  relief  of  the  hyperemia  and 
edema  about  the  strictured  area.  In  this  operation  a  small  needle 
should  be  selected  and  the  point  introduced  just  above  the  symphysis, 
the  direction  being  at  a  right  angle  to  the  vertical  axis  of  the  body. 

In  cases  of  obstinate  deep  strictures  of  larger  calibre  which  will  not 
yield  to  dilatation,  or  in  which  the  passage  of  a  sound  provokes  urethral 
fever  or  bladder  irritability,  and  when  the  patient  is  unwilling  to 
sacrifice  the  necessary  time,  external  perineal  urethrotomy  with  a 
guide  may  be  practised.  This  is  an  operation  similar  to  the  procedure 
just  described,  but  is  much  simpler  for  the  reason  that  a  grooved  staff 
is  introduced  first  and  the  cut  into  the  urethra  is  made  upon  the  staff. 
After  division  of  all  strictured  tissue  the  bladder  is  drained  as  described 
above. 


686 


DISEASES  OF   THE  BLADDER  AND   URETHRA 


Anterior  strictures  of  the  urethra  (within  five  inches  of  the  meatus) 
may  be  treated  by  internal  urethrotomy.  General  anesthesia  is  not 
necessary,  but  is  often  desirable.  If  local 
anesthesia  is  employed,  about  |  dram  of  a  4 
per  cent,  solution  of  cocaine  is  introduced  into 
the  bulbous  urethra  by  means  of  a  long- 
pointed  syringe,  and  retained  by  compressing 
the  lips  of  the  meatus  for  five  minutes.  A 
drop  of  the  same  solution  is  next  introduced 
just  below  the  meatus  with  a  hypodermic 
syringe.  The  urethra  and  glans  are  then 
thoroughly  cleansed  with  a  solution  of  mer- 
curic chloride.  The  meatus,  if  strictured,  is 
divided  downward  to  the  full  size  of  the 
canal  and  the  other  bands  accurately  located 
with  bulbous  bougies.  An  Otis  dilating  ure- 
throtome (Fig.  323)  is  then  introduced  to  such 
a  depth  that  the  blade  as  it  emerges  is  just 
behind  the  stricture.  The  dilator  is  opened 
to  the  full  size  of  the  urethra,  putting  the 
stricture  on  the  stretch.  The  blade  is  then 
drawn  quickly  upward  and  downward  twice, 
the  dilator  partly  closed,'  and  the  urethrotome 
removed.  The  hemorrhage  is  apt  to  be  free 
for  a  moment,  but  soon  ceases,  after  which 
the  canal  is  irrigated  with  a  hot  solution  of 
mercuric  chloride  (1  to  10,000),  a  full-sized 
sound  passed,  and  a  dressing  of  aseptic  gauze 
applied  to  the  penis.  Behind  the  meatus  the  cut 
should  always  be  made  in  the  roof  of  the  canal. 
Before  each  urination  the  dressings  should  be 
removed  and  the  meatus  bathed  with  the  bi- 
chloride solution.  After  the  bladder  is  emptied 
the  dressing  should  be  reapplied.  During  the 
first  few  days  the  patient  should  remain  in 
bed  on  account  of  the  danger  of  hemorrhage, 
which  may  occur  spontaneously,  but  generally 
takes  place  after  urination  or  as  a  result  of  an 
erection.  Gently  pressing  the  lips  of  the 
meatus  together  for  five  minutes  and  assum- 
ing the  recumbent  posture  in  bed  will  serve 
to  check  it  in  the  majority  of  instances. 

After  all  operations  for  stricture  full-sized 
sounds  should  be  passed,  at  first  every  three 
days,  later  once  a  week;   and  if  there  is  a  ten- 
dency to  recontraction,  at  least  once  a  month 
urethrotome.  as  long  as  the  tendency  is  manifest. 


Fig. 


TUMORS  OF  THE   URETHRA  687 

Urethral  Calculus. — Calculi  sometimes  lodge  in  the  prostatic  urethra, 
behind  strictures,  or  in  the  fossa  navicularis.  These  occur  commonest 
in  children,  and  may  give  rise  to  complete  retention  of  urine.  The 
seat  of  the  impaction  is  determined  by  the  presence  of  localized  pain 
and  tenderness  and  by  contact  with  a  urethral  sound.  They  may  be 
primary,  formed  chiefly  from  continued  phosphatic  deposit,  behind 
a  stricture,  or  they  may  be  secondary,  entering  the  urethra  from  the 
bladder.  There  is  often  a  previous  history  of  ureteral  or  renal  colic. 
If  they  cannot  be  forced  outward  or  backward,  an  external  perineal 
urethrotomy  should  be  performed  and  the  stone  removed  by  means 
of  a  small  scoop  or  curet. 

FOREIGN   BODIES. 

Foreign  bodies  are -not  infrequently  introduced  into  the  urethra  and 
become  impacted.  They  may  determine  the  presence  of  a  urethral 
discharge.  The  diagnosis  is  made  by  palpation  or  with  the  urethro- 
scope, and  the  treatment  is  removal  either  with  forceps  or  by  external 
urethrotomy. 

TUMORS    OF    THE    URETHRA. 

Epithelioma. — Primary  epithelioma  of  the  urethra  has  been  reported 
but  is  exceedingly  rare.  There  are  about  50  cases  reported  in  the 
literature.  It  occurs  most  frequently  in  the  region  of  the  bulb.  The 
disease  is  rarely  recognized  early,  the  first  symptoms  generally  being 
retention  of  urine  and  the  presence  of  a  swelling  in  the  perineum. 
Hemorrhage  and  a  purulent  discharge  are  present  in  certain  cases  and 
sexual  irritability  may  occur.  Examination  usually  detects  the 
presence  of  stricture.  Involvement  of  the  inguinal  lymph  nodes  is 
a  late  manifestation. 

Treatment.— In  the  treatment  of  this  condition  three  methods  have 
been  employed:  Simple  excision  with  cauterization  (Koenig),  resec- 
tion of  the  urethra  (Rupprecht),  and  amputation  of  the  penis  (Miku- 
licz). Although  only  a  few  permanent  cures  have  been  reported  thus 
far,  they  are  sufficient  to  encourage  surgeons  to  advise  radical  operation 
in  all  such  cases. 

Benign  Growths — Benign  growths  of  the  urethra  occur  more  fre- 
quently. These  are  papillomata,  which  may  occur  just  within  the 
meatus,  and  a  fungoid  pedunculated  polyp,  sometimes  found  at  or 
near  the  bulbomembranous  junction.  Lacunar  cysts  and  cysts  of 
Cowper's  gland  ducts  and  the  sinus  pocularis  are  occasionally  ob- 
served. These  growths  rarely  give  rise  to  marked  symptoms  unless 
they  reach  a  size  to  produce  obstruction.  Occasionally  they  cause 
localized  pain  on  urination  and  may  give  rise  to  a  mucous  discharge, 
paresthesia3,  and  hemorrhage.  The  diagnosis  can  onlv  be  made  by  the 
endoscope.  The  treatment  should  be  excision  through  an  endoscopic 
tube  with  cauterization  of  the  removal  site.  Some  of  these  tumors 
are  highly  vascular,  and  the  bleeding  following  their  removal  may  be 
considerable.    Cysts  should  be  incised  and  cauterized. 


CHAPTER   XXIV. 
INJURIES  AND  DISEASES  OF  THE  PENIS  ANT)  SCROTUM. 

INJURIES    OF    THE    PENIS    AND    SCROTUM. 

Contusions. — ( Jontusions  of  the  penis  differ  in  no  way  from  contusions 
in  other  superficial  regions  of  the  body,  unless  the  injury  is  such  as 
to  cause  rupture  of  the  corpus  spongiosum  or  one  of  the  corpora 
cavernosa.  Bleeding  is  usually  severe,  and  in  these  cases  it  is  often 
associated  with  rupture  of  the  urethra.  An  extensive  hematoma  may 
form,  which  occasionally  requires  open  incision,  removal  of  the  clots, 
and  packing.  Contusions  of  the  scrotum  often  result  in  extensive 
hematomata,  either  in  the  cellular  tissue  or  into  the  cavity  of  the 
tunica  vaginalis.  When  in  the  latter  situation  the  condition  is  called 
hematocele.  If  of  moderate  size,  these  hematomata  require  no  treat- 
ment other  than  rest  and  the  application  of  heat  or  cold.  If  large, 
and  especially  if  they  continue  to  increase  in  size,  they  should  be 
treated  by  free  incision,  removal  of  the  clots  and  fluid  blood,  ligature 
of  any  bleeding  vessel,  and  closure  with  or  without  drainage.  If 
infection  and  suppurative  inflammation  should  occur  incision  and 
drainage  is  indicated.  The  urethra  should  be  examined  to  detect  if 
present  an  associated  rupture  which  might  lead,  if  overlooked,  to 
extravasation  and  retention  of  urine.  Herniation  of  the  penis  out  of 
its  fibrous  sheath  or  fracture  may  occur.  These  conditions  are  usually 
associated  with  more  extensive  general  injuries. 

Wounds  of  the  Penis  and  Scrotum — Wounds  of  the  penis  and  scro- 
tum not  involving  the  urethra  or  testicles  should  be  treated  as  wounds 
in  other  locations. 

INFLAMMATORY    DISEASES. 

Cellulitis. — Cellulitis  of  the  penis  or  scrotum  may  follow  infected 
wounds  or  venereal  ulcers.  If  the  infection  is  mild  in  character  it  may 
resolve  under  local  treatment  of  acetate  and  aluminum,  or  an  abscess 
may  form  which  will  require  incision  and  drainage. 

If  the  infection  is  more  virulent,  or  if  the  resistance  of  the  indi- 
vidual is  lowered,  more  or  less  extensive  sloughing  of  the  superficial 
tissues  may  occur.  The  treatment  should  be  the  same  as  in  other 
localities. 

Balanitis. — Balanitis  or  balanoposthitis  is  a  local  inflammation  of 
the  skin  of  the  prepuce  and  the  mucous  membrane  of  the  glans.     It 


/  A'  FL .  I  M  MA  TOR  Y   1)1  SEA  SKS  I  is'.  I 

is  predisposed  to  by  phimosis,  uncleanliness,  and  the  retention  of 
irritating  discharges,  and  is  often  associated  with  subpreputial  ulcera- 
tion or  neoplasm.  There  is  itching  and  burning;  thick  purulent  dis- 
charge often  with  swelling  and  edema  of  the  prepuce.  The  opposed 
surfaces  of  prepuce  and  glans  may  present  excoriations  and  superficial 
ulcerations.  When  tight  phimosis  is  present  the  condition  may  become 
chronic,  giving  rise  to  inflammatory  thickening  and  cicatricial  narrowing 
of  the  preputial  orifice.  Treatment  consists  in  separation  of  the  opposed 
surfaces  with  removal  of  the  cause  and  frequent  cleansing  and  irriga- 
tion of  the  preputial  cavity.  When  chronic  thickening  and  fibrosis 
are  present  circumcision  offers  prompt  and  permanent  relief. 

Herpes  Progenitalis. — This  is  of  fairly  frequent  occurrence  in 
individuals  with  phimosis,  and  in  others  whose  habits  are  not  cleanly. 
It  also  occurs  in  neurotic  subjects  often  without  local  irritation.  The 
disease  manifests  itself  by  the  appearance  of  a  small  group  of  vesicles 
just  behind  the  corona,  which  mav  also  extend  to  the  glans.  These 
soon  rupture,  leaving  small  areas  of  superficial  ulceration  with  a 
surrounding  area  of  redness.  In  some  instances  there  are  practically 
no  subjective  sensations;  generally,  however,  there  are  itching,  burn- 
ing, and  moderate  soreness.  If  a  secondary  infection  occurs,  more  or 
less  cellulitis  may  develop  with  involvement  of  the  inguinal  lymph 
nodes. 

The  treatment  should  consist  in  circumcision  if  phimosis  is  present, 
cleanliness,  and  the  local  use  of  iodol  or  aristol  powder. 

Chancroid  or  Simple  Venereal  Ulcer. — This  includes  all  of  the 
venereal  sores  except  the  initial  lesion  of  syphilis.  The  Ducrey-Unna 
bacillus  is  believed  to  be  the  specific  cause.  It  is  usually  found  in 
smears  and  in  pus  from  the  inguinal  bubo  but  cannot  always  be 
obtained  in  pure  culture.  The  disease  exhibits  a  tendency  to  self- 
limitation  and  runs  an  average  course  of  from  three  to  five  weeks. 
The  site  of  election  is  the  coronal  sulcus  near  the  frenum,  or  the  pre- 
putial margin.  The  lesion  varies  from  a  slightly  infected  abrasion  or 
herpetic  ulceration  to  the  most  virulent  form  of  gangrenous  cellulitis 
(phagedenic  chancroid).  The  lesions  are  often  multiple  and  frequently 
appear  at  first  as  one  or  more  small  pustules.  These  may  rupture  and 
extend  peripherally,  and  by  their  coalescence  form  large  sloughing 
ulcers  with  irregular  undermined  edges.  The  surrounding  tissues  are 
reddened  and  edematous  and  the  inguinal  lymph  nodes  enlarge  and 
become  tender.  The  disease  is  a  painful  one  and  often  protracted 
from  the  suppuration  which  frequently  takes  place  in  the  inguinal 
lymph  nodes  (chancroidal  bubo).  If  the  case  is  an  early  one  an  attempt 
may  be  made  by  radical  cauterization  to  transform  the  specific  ulcera- 
tion into  a  simple  one.  Nitric  acid  is  the  most  powerful  caustic  for 
this  purpose. 

Expectant  treatment  consists  in  cleanliness  and  the  use  of  antiseptic 
dressings  and  washes.  If  drainage  is  interfered  with  by  a  tight  pre- 
puce a  dorsal  or  lateral  slits  may  become  necessary  with  a  plastic 
44 


690  DISEASES  OF   THE  PENIS  AND  SCROTUM 

circumcision  after  healing  has  taken  place.  Single  chancroidal  infec- 
tion is  relatively  rare  and  it  is  safer  to  consider  the  lesion  to  he  syphilitic 
until  proved  not  to  be  so. 

Chancre. — Chancre,  or  the  initial  lesion  of  syphilis,  is  described  on 
page  61,  in  the  section  devoted  to  Syphilis. 

It  must  be  remembered  that  mixed  venereal  ulcers  are  frequently 
observed  where  the  patients  have  been  exposed  to  both  kinds  of 
infection. 

In  these  cases  the  early  appearance  of  the  lesion  may  be  character- 
istic of  herpes  or  of  chancroid,  the  typical  syphilitic  induration  develop- 
ing only  after  the  lapse  of  two  or  three  weeks.  One  should,  therefore, 
be  guarded  in  prognosis  in  every  case  of  venereal  ulcer  until  sufficient 
time  has  elapsed  to  allow  the  syphilitic  characteristics  to  appear, 
A  dark  field  examination  should  be  made  and  in  all  doubtful  cases 
the  Wassermann  test  should  be  applied. 

Phimosis. — Phimosis  is  a  stenosis  of  the  preputial  orifice  preventing 
retraction  of  the  foreskin.  This  is  generally  a  congenital  affection, 
but  may  result  from  cicatricial  narrowing,  from  the  healing  of  a 
venereal  ulcer,  or  as  a  result  of  trauma.  In  children  there  may  be 
adhesions  between  the  glans  and  prepuce,  and  a  collection  of  smegma 
just  behind  the  corona  from  the  retained  secretions  of  the  coronal 
glands.  The  condition,  as  a  rule,  produces  no  symptoms,  but  occa- 
sionally there  is  itching  or  sense  of  discomfort  in  the  parts,  and 
not  infrequently  a  balanitis  is  present.  In  highly  nervous  individuals 
the  condition  may  give  rise  to  a  more  or  less  constant  sexual  irritation, 
evidenced  by  frequent  erections,  erotic  dreams,  and  seminal  emissions. 
In  younger  children,  nocturnal  incontinence  of  urine  may  occur. 

Treatment. — In  infants  the  prepuce  usually  can  be  stretched  suffi- 
ciently to  allow  the  glans  to  be  uncovered.  If  this  is  impossible, 
or  if,  after  retraction,  too  much  constriction  exists,  a  simple  dorsal 
incision  is  generally  all  that  will  be  required  unless  the  foreskin  is 
abnormally  redundant.  In  older  children  and  adults,  and  in  infants 
with  an  excessive  length  of  prepuce,  circumcision  is  to  be  advised. 

Two  satisfactory  methods  of  circumcision  are  as  follows:  Either 
general  or  local  anesthesia  may  be  employed ;  the  former  is  generally  to 
be  preferred  in  young  children.  (1)  After  careful  disinfection  of  the 
parts  the  foreskin  is  drawn  gently  and  evenly  downward,  and  that  part 
projecting  beyond  the  apex  of  the  glans  cut  off  obliquely  from  above, 
downward  and  outward  to  enlarge  the  opening  (Fig.  324).  The  skin 
retracts  and  the  mucous  layer  of  the  prepuce  is  exposed.  This  layer  is 
slit  dorsally  as  far  as  the  coronal  sulcus  and  the  redundancy  is  removed 
with  scissors.  The  bleeding  points,  usually  a  dorsal,  two  lateral, 
and  a  f renal,  are  secured  if  necessary.  The  parts  retracted  and  united 
with  catgut  sutures,  after  which  a  dressing  of  sterile  gauze  is  applied, 
(2)  The  preputial  orifice  is  tensed  upon  the  glans.  Three  clamps,  two 
dorsal  and  one  median  ventral,  are  applied.  The  prepuce  is  slit  between 
the  two  dorsal  clamps  with  scissors  or  upon  a  grooved  director  as  far 


IS  FLA  MMATOh'Y   DISEASES 


693 


as  the  coronal  sulcus.  The  two  flaps  outlined  between  this  slit  and 
the  frenum  are  removed  by  trimming  close  to  the  coronal  sulcus,  care 
being  taken  to  leave  a  narrow  ledge  of  mucous  membrane  for  suture. 


Fig.  324. — Circumcision. 

Paraphimosis. — This  condition,  which  is  fairly  common,  results 
from  forcibly  retracting  an  abnormally  narrow  prepuce.  The  con- 
stricted part,  after  it  is  drawn  backward  behind  the  corona,  exerts 
pressure  on  the  veins  and  causes  the  glans  and  adjacent  tissues  to 
swell  and  become  markedly  edematous.  In  extreme  cases  considerable 
sloughing  may  occur.      An  edematous  collar  of  mucous  membrane 


Fi<;.  325. — Reduction  of  paraphimosis.     (Phillips.) 

is  usually  seen  just  behind  the  corona  and  above  this  a  sulcus  indicating 
the  position  of  the  constricting  band.  Sometimes  a  second  edematous 
collar  and  sulcus  may  be  observed.     The  condition  is  a  painful  one, 


692  DISEASES  OF   THE  PENIS  AND  SCROTUM 

and  if  neglected,  reduction  by  the  ordinary  non-operative  means 
becomes  impossible.  In  the  early  stages  the  penis  should  be  thoroughly 
lubricated,  surrounded  with  hot  gauze  compresses,  and  the  parts 
gently  but  firmly  squeezed  with  the  hand  to  drive  the  blood  out  of 
the  glans  and  to  reduce  its  size.  The  edematous  prepuce  is  then 
drawn  forward  with  the  thumb  and  index  finger  of  one  hand,  while 
the  glans  is  pressed  backward,  as  shown  in  Fig.  325.  When  reduction 
cannot  be  effected  by  this  plan,  an  anesthetic  should  be  administered, 
the  constricting  band  freely  divided,  and  a  more  or  less  typical 
circumcision  performed. 

TUMORS  OF  THE  PENIS  AND  SCROTUM. 

Papilloma. — Papillomata,  or  warts,  are  exceedingly  common  on  the 
glans  and  prepuce.  They  are  usually  found  in  the  coronal  sulcus  and 
on  either  side  of  the  frenum.  They  appear  also  on  the  scrotum.  When 
in  the  region  of  the  glans  penis,  they  are  usually  associated  with  phi- 
mosis or  other  conditions  producing  irritation  and  an  excessive  amount 
of  moisture  of  the  parts,  especially  balanitis  and  gonorrhea.  They 
are  to  be  distinguished  especially  from  syphilitic  condyloma  and 
epithelioma.  In  case  of  doubt  a  microscopic  examination  of  the 
tissue  should  be  made.  Papillomata  are  not  common  in  elderly 
individuals.    Wart  horns  are  occasionally  observed  in  this  region. 

Sebaceous  cysts,  dermoids,  lipomata,  and  other  innocent  growths 
have  been  observed  in  the  scrotum. 

Epithelioma. — Epithelioma  occurs  both  on  the  penis  and  scrotum; 
most  commonly  on  the  glans,  where  it  frequently  develops  from 
a  papilloma,  more  rarely  from  a  chronic  ulcer.  In  the  former  case  the 
growth  may  resemble  at  first  a  papilloma;  later  the  surrounding 
tissues  become  infiltrated,  and  ulceration  occurs.  If  the  growth 
becomes  infected  its  original  papillomatous  character  is  often  obscured. 
When  developing  from  an  ulcer  there  may  be  no  papillomatous  growth, 
but  a  progressively  infiltrating  ulcer,  which  later  may  extend  to  the 
scrotum.  The  growth  may  be  concealed  under  a  tight  phimosis  and  is 
often  accompanied  by  a  serous,  purulent  or  fetid  discharge.  The 
inguinal  lymph  nodes  are  involved  early  in  the  disease.  Cancer  of 
the  penis  seems  to  be  less  malignant  than  in  any  other  parts  of  the 
genito-urinary  system,  and  in  a  considerable  number  of  instances 
cures  have  followed  radical  removal.  In  fact,  Legueu  reports  the 
case  of  an  elderly  patient  with  extensive  epithelioma  where  he  removed 
the  penis  and  scrotum,  but  left  enlarged  inguinal  lymph  nodes  owing 
to  his  feeble  condition.  He  remained  well  and  without  recurrence 
for  four  years.  The  enlarged  inguinal  nodes  gradually  diminished  in 
size. 

Sarcoma. — Sarcoma  of  the  penis  is  rare,  and  from  the  18  reported 
cases  is  much  more  malignant  than  carcinoma.  Endothelioma  has 
been  reported  in  a  few  instances. 


TUMORS  OF   THE  PENIS  AND  SCROTUM  693 

Epithelioma   of   the    Scrotum.— Epithelioma   of   the   scrotum,   or 

chimney-sweep's  cancer,  is  apparently  more  frequently  observed  in 
England  than  elsewhere.  It  begins  by  what  is  described  as  a  "soot- 
wart,"  which  may  occur  on  any  part  of  the  scrotum,  more  commonly  on 
the  lower  and  front  part,  and  for  a  long  time  remains  as  an  apparently 
innocent  papilloma.  Later,  ulceration  occurs,  which  gradually  spreads 
and  is  accompanied  by  enlarged  lymph  nodes  in  the  groin,  which  in 
turn  break  down,  leaving  extensive  ulcerated  areas  often  exposing 
the  iliac  vessels.  The  lesion  in  the  lymph  nodes  is  often  inflammatory; 
true  metastases  are  late  to  develop  as  a  rule.  Rarely  the  primary 
growth  may  remain  small,  while  the  inguinal  metastases  assume  a 
large  size,  giving  rise  to  the  belief  that  the  primary  growth  occurred  in 
that  region.  The  testicles  not  infrequently  become  invaded  and  the 
crura  of  the  penis  may  be  involved. 

Treatment. — Papillomata  of  the  penis  often  disappear  sponta- 
neously when  the  conditions  which  favor  their  production  are  removed. 
Hence  circumcision  and  treatment  addressed  to  chronic  urethral 
discharges  may  be  indicated.  Excision  of  the  individual  tumors  with 
the  knife,  scissors,  or  snare  is  to  be  preferred  to  treatment  by  caustics. 
In  cases,  however,  which  present  an  extensive  base,  the  entire  area  may 
be  curetted  off  and  the  removal  site  cauterized.  Recurrences  are 
common.  The  treatment  of  other  innocent  growths  in  this  region  is 
the  same  as  in  other  parts  of  the  body. 

Epithelioma  of  the  penis  should  be  treated  by  amputation  of  the 
organ  and  removal  of  the  inguinal  lymph  nodes. 

In  the  early  stage  of  the  disease,  when  the  growth  is  limited  to  the 
glans,  the  amputation  can  be  made  about  the  middle  of  the  organ. 
Considerable  hemorrhage  may  follow  division  of  the  corpora  caver- 
nosa, which  is  best  controlled  by  buried  sutures.  The  skin  is  then 
united  to  the  urethra  by  a  few  absorbable  sutures.  In  more  advanced 
cases  total  amputation  should  be  performed.  In  this  operation  the 
corpora  cavernosa  should  be  completely  removed,  the  crura  being 
cut  close  to  the  pubic  arch,  the  entire  chain  of  lymph  nodes  and 
surrounding  areolar  tissue  in  both  inguinal  regions  dissected  out,  and 
the  urethra  sutured  in  the  perineum.  It  is  occasionally  necessary  to 
sacrifice  both  testicles  and  the  scrotum. 

Free  excision  of  soot-warts  is  to  be  advised  as  soon  as  they  appear, 
for  at  first,  they  are  frequently  innocent  and  show  no  tendency  to 
recur  after  removal.  Later  the  scrotum  should  be  protected  by  proper 
clothing.  When  the  disease  assumes  a  malignant  character  it  should 
be  extensively  removed,  sacrificing  the  testicles  if  necessary,  and 
removing  all  the  areolar  tissue  and  lymphatics  of  both  inguinal  regions. 
The  inguinal  lymph  nodes  should  be  removed  with  the  growth,  as 
metastases  have  been  known  to  develop  years  after  the  excision  of  the 
primary  tumors. 

Varicocele. — Varicocele  is  a  varicose  or  dilated  condition  of  the 
veins  of  the  spermatic  cord.    It  may  be  symptomatic  resulting  from 


G94  DISEASES  OF   THE  PEXIS  AXD  SCROTUM 

abnormal  intra-abdominal  pressure  and  is  not  infrequently  -ecu 
accompanying  new  growths  of  the  kidney,  and  in  all  cases  of  rapidly 
developing  left  sided  varicocele,  the  kidney  should  first  be  excluded  as 
a  possible  causative  factor. 

Idiopathic  varicocele  developing  without  demonstrable  cause  is 
of  frequent  occurrence,  being  present  to  some  degree  in  about  10 
per  cent,  of  all  adult  males  (Keyes).  In  the  vast  majority  of  cases 
it  occurs  on  the  left  side,  for  the  reason  that  the  venous  blood-pressure 
is  greatest  on  this  side  owing  to  the  greater  length  of  the  left  spermatic 
vein  and  its  rectangular  implantation  into  the  renal  vein.  It  will  be 
remembered  that  as  the  spermatic  cord  emerges  at  the  external  abdomi- 
nal ring  the  spermatic  veins  divide  into  a  large  number  of  trunks,  some 
of  which  adhere  closely  to  the  vas  deferens  and  its  artery,  while  others 
are  more  or  less  separated  from  the  vas  by  loose  areolar  tissue.  In  a 
condition  of  varicocele  all  of  these  branches  become  dilated,  elongated, 
and  their  walls  thickened  and  often  thrombosed.  The  disease  is 
expecially  apt  to  involve  the  larger  anterior  group  of  veins  which 
accompany  the  spermatic  artery.  This  produces  an  increased  weight 
for  the  dartos  to  support,  and  as  it  gradually  yields,  the  left  half  of  the 
scrotimi  with  its  mass  of  veins  and  testicle  sags  lower  and  lower  until 
it  hangs  from  one  to  three  inches  below  its  fellow.  The  condition  pre- 
sents no  serious  complications  or  sequelae  although  it  is  occasionally 
followed  by  atrophy  of  the  testicle. 

Symptoms. — The  symptoms  of  varicocele  are  of  two  kinds,  the  local 
and  the  nervous.  Local  symptoms  may  be  entirely  absent,  and  the 
condition  may  be  discovered  by  accident  by  the  patient,  or  his  atten- 
tion may  first  be  directed  toward  it  by  his  medical  adviser.  When 
large,  the  varicocele  may  cause  a  sense  of  weight  and  sometimes 
dragging  pain  in  the  scrotum  and  groin,  which  are  relieved  on  lying 
down  and  increased  by  severe  bodily  strain.  Atrophy  of  the  testicle 
occasionally  occurs.  The  nervous  symptoms  are  varied  in  character 
but  correspond  to  the  group  usually  present  in  sexual  neurasthenia. 
Sexual  weakness,  premature  ejaculation,  and  erotic  fancies  are  the 
chief  complaints. 

Diagnosis. — The  diagnosis  of  varicocele  is  not  difficult.  Enlarge- 
ment of  one-half  of  the  scrotum  and  the  presence  of  the  dilated  veins, 
which  give  to  the  examining  hand  the  sensation  of  a  mass  of  earth 
worms,  are  pathognomonic  of  the  condition.  The  veins  are  emptied 
when  the  patient  assumes  the  recumbent  posture,  but  quickly  refill 
when  the  erect  position  is  again  taken.  Pressure  over  the  inguinal 
ring  applied  while  the  patient  is  on  his  back  and  maintained  after 
h  >  rises,  will  retard  but  not  prevent  refilling  of  the  veins,  unless  the 
pressure  is  such  as  to  occlude  the  arteries. 

Treatment. — In  mild  cases  without  symptoms  no  treatment  is  re- 
quired. If  there  is  a  certain  amount  of  pain  or  dragging  sensation,  the 
wearing  of  a  suspensory  bandage  will  often  give  prompt  relief.  In 
the  severer  cases,  in  which  the  symptoms  are  progressive  or  are  of 


TUMORS  OF  THE  PENIS  AND  SCROTUM  695 

sufficient  moment  to  justify  the  use  of  more  radical  measures,  opera- 
tion is  advisable,  which  may  be  performed  in  the  following  maimer: 
After  the  usual  preparation  of  the  patient,  ether  is  administered  and 
an  incision  one  inch  in  length  is  made  oxer  the  spermatic  cord  as  it 
emerges  from  the  external  abdominal  ring.  Through  this  incision 
about  two  inches  of  the  cord  are  withdrawn,  drawing  the  testicle  to 
the  upper  part  of  the  scrotal  pouch.  The  various  tunics  are  then 
carefully  divided  until  the  large  mass  of  dilated  veins  is  reached. 
These  are  easily  separated  from  the  small  mass  which  surrounds  the 
vas  deferens,  which  should  not  be  disturbed.  The  large  mass  is 
drawm  outward,  freely  separated  from  the  rest  of  the  cord,  and  double 
ligated  with  chromicized  catgut,  one  ligature  being  placed  near  the 
external  ring  and  the  other  just  above  their  junction  with  the  tissues 
of  the  epididymis.  .  After  the  ligatures  are  applied  the  intervening 
mass  is  cut  away,  the  two  stumps  approximated  by  tying  the  ends  of 
the  upper  and  lower  ligatures.  The  cut  surfaces  are  then  sutured 
together  and  the  wound  closed  without  drainage.  Many  surgeons  make 
the  incision  through  the  tissues  of  the  scrotum.  There  is  no  advantage 
in  this,  and  the  writer  believes  there  is  more  risk  of  infection  on  account 
of  the  corrugated  skin  and  difficulty  in  keeping  the  dressings  snugly 
applied.  Operation  is  not  infrequently  followed  by  a  more  or  less 
extensive  fibrosis  of  the  testicle.  A  temporary  enlargement  of  the 
organ  is  usually  noted  for  a  few  days  after  operation. 

Hydrocele. — Hydrocele  is  a  collection  of  fluid  in  the  tunica  vaginalis 
testis.  This  may  be  due  to  an  acute  inflammation  of  the  epididymis 
(acute  hydrocele),  to  a  chronic  inflammatory  process  of  the  tunica, 
to  trauma,  and  to  other  conditions  the  nature  of  which  is  not  well 
understood.  Acute  hydrocele  almost  always  accompanies  inflamma- 
tions of  the  testicle  or  epididymis,  and  is  sometimes  observed  as  a  com- 
plication of  the  acute  infectious  diseases.  It  is  characterized  by  its 
sudden  onset  and  the  development  of  a  tense  painful  swelling  in  the 
scrotum.  It  is  usually  accompanied  by  dragging  pain  and  the 
symptoms  of  the  condition  which  it  complicates.  It  may  be  con- 
founded with  strangulated  hernia  in  children.  The  fluid  is  usually 
scanty,  and  tends  to  disappear  spontaneously  but  paracentesis  is 
sometimes  indicated  to  relieve  pain.  If  suppuration  occurs  which  is 
rare,  the  tunica  vaginalis  must  be  incised  and  treated  as  an  abscess 
cavity. 

Chronic  hydrocele  is  most  frequently  observed  in  middle  and  old  age. 
It  affects  both  sides  with  equal  frequency  and  is  sometimes  double  Fig. 
326.  It  is  predisposed  to  by  conditions  tending  to  produce  chronic  stasis 
and  its  onset  is  not  infrequently  determined  by  some  previous  inflam- 
matory condition.  Trauma  appears  to  be  a  factor  in  some  instances. 
In  cases  of  rapid  development  the  tunica  vaginalis  is  distended  and 
thin,  but  in  those  of  long  standing  there  may  be  a  good  deal  of  chronic 
inflammatory  thickening.  The  condition  is  aggravated  by  recurrent 
injuries  and  frequent  tapping.     The  hydrocele  sac  is  usually  pyri- 


696  DISEASES  OF  THE  PENIS  AND  SCROTUM 

form  in  shape  partially  surrounding  the  testicle  and  epididymis  which 
are  to  be  found  behind  and  below  it.     The  amount  of  fluid  varies 


Fig.  326.— Double  hydrocele. 


Fig.  327.— Hydrocele. 


TUMORS  OF  THE  PENIS   AND  SCROTUM  697 

from  a  few  ounces  to  accumulations  of  enormous  size.  It  is  usually 
pale  yellow  with  a  specific  gravity  of  1022  to  1026  and  presents  the 
laboratory  features  of  any  chronic  exudate.  The  tumor  may  produce 
a  certain  degree  of  mechanical  discomfort  depending  upon  its  weight 
and  size.  It  usually  develops  without  other  symptoms.  Tumors  of 
large  size  may  draw  down  the  skin  of  the  pubic  region,  completely  bury- 
ing the  penis  between  its  folds.  The  swelling  is  at  first  oval  but  soon 
becomes  pear-shaped  (Fig.  327).  It  presents  a  smooth,  tense  surface 
and  is  covered  by  normal  freely  movable  skin.  Its  consistency  is 
elastic;  fluctuation  and  sometimes  a  fluid  wave  may  be  elicited.  The 
tumor  is  found  to  be  translucent  on  transillumination  unless  the 
contents  are  unusually  opaque  as  is  sometimes  the  case  with  chylous 
fluids.  The  diagnosis  may  be  established  by  the  introduction  of  a 
needle  and  the  withdrawal  of  a  straw-colored  fluid,  not  spontaneously 
coagulable  containing  albumin  and  cholesterin  crystals. 

Hydrocele  of  the  cord  is  a  circumscribed  collection  of  fluid  in  some 
unobiliterated  portion  of  the  funicular  process  along  the  cord.  One  or 
more  small  oval  elastic  tumors  may  be  seen  over  the  region  of  the 
spermatic  cord.  It  sometimes  happens  that  two  hydrocele  cavities 
may  be  connected  by  a  narrow  passage,  the  so-called  bilocular  hydro- 
celes.   Double  hydrocele  (Fig.  326)  is  rare. 

Congenital  hydrocele  is  a  collection  of  fluid  in  the  unclosed  funicular 
process  of  the  peritoneum,  and  is  generally  associated  with  the  presence 
of  a  congenital  hernia.  The  characteristic  sign  of  this  form  of  hydro- 
cele is  that  it  disappears  when  the  child  assumes  the  recumbent 
posture,  but  reappears  when  he  stands  erect. 

Chylous  hydrocele  is  a  distension  of  the  tunica  vaginalis  wTith  a 
milky  fluid  resembling  chyle.    It  is  due  to  filariasis. 

Treatment. — The  palliative  treatment  of  hydrocele  consists  in 
tapping  the  cyst  and  withdrawing  the  fluid.  To  tap  a  hydrocele  prop- 
erly the  scrotum  should  be  disinfected  and  rendered  tense  by  grasping 
it  firmly  with  the  hand.  A  sterile  trocar  is  then  introduced  through 
the  anterior  wall,  the  instrument  being  directed  somewhat  upward 
and  backward  to  avoid  wounding  the  testicle,  care  being  taken  to 
avoid  bloodvessels.  After  the  fluid  is  withdrawn  the  opening  is 
closed  with  a  bit  of  sterile  cotton  and  collodion.  The  fluid  slowly 
returns  and  the  process  has  to  be  frequently  repeated,  usually  in 
from  three  to  six  months,  the  intervals  becoming  shorter  with  each 
repetition  of  the  procedure. 

The  radical  cure  of  hydrocele  is  effected  by  two  methods,  that  by 
injection  of  pure  carbolic  acid  into  the  sac,  and  the  open  operation. 

If  the  injection  method  is  to  be  practised,  the  scrotum  is  prepared, 
in  the  usual  manner,  and  the  needle  of  a  hypodermic  syringe  contain- 
ing 5  or  10  drops  of  pure  carbolic  acid  is  thrust  into  the  upper  part 
of  the  sac  and  held  by  an  assistant.  The  surgeon  then  introduces  a 
trocar  below  and  withdraws  the  fluid.  When  the  sac  is  emptied,  the 
needle  of  the  syringe  still  being  within  the  sac,  the  carbolic  acid  is 


69S  DISEASES  OF  THE  PENIS  AND  SCROTUM 

injected  and  evenly  distributed  by  rubbing  the  walls  together.  Both 
openings  are  then  sealed  and  the  patient  placed  in  bed.  A  certain 
amount  of  pain  and  swelling  of  the  parts  occurs  during  the  succeeding 
forty-eight  hours,  but  this  quickly  subsides.  A  cure  by  this  method 
may  be  expected  in  about  90  per  cent,  of  the  cases. 

Several  open  operations  are  practised.  The  simplest  one  is  to  make 
an  incision  into  the  sac,  evacuate  the  fluid,  and  apply  pure  carbolic 
acid  to  the  interior  by  means  of  a  cotton  swab,  after  which  the  wound 
is  partly  united  with  sutures  and  a  small  gauze  or  rubber  tissue  drain 
left  in  the  cavity  for  two  or  three  days.  Another  method  is  to  incise, 
evacuate  the  fluid,  and  pack  the  cavity  with  gauze.  A  third  method 
and  perhaps  the  surest  of  all,  is  to  incise  the  sac  freely  and  then  dissect 
out  its  parietal  layer,  arrest  bleeding,  and  partly  close  the  wound,  pro- 
viding drainage  by  a  gauze  packing  or  the  introduction  of  a  small 
folded  piece  of  rubber  tissue.  Recently  several  surgeons  have  advised 
the  following  simple  procedure,  which  seems  to  be  satisfactory.  After 
incision  through  the  scrotum,  exposing  the  tunica  vaginalis,  the  latter 
is  opened  by  a  small  longitudinal  cut  and  the  fluid  allowed  to  escape. 
The  testicle  is  then  drawn  outward  through  the  opening  in  the  tunica, 
which  is  thereby  completely  everted,  leaving  its  serous  surface  in  con- 
tact with  the  areolar  tissue  of  the  scrotum.  The  cutaneous  wound  is 
then  closed  without  drainage. 

All  of  the  open  methods  require  a  period  of  convalescence  of  from 
ten  days  to  two  weeks. 


CHAPTER   XXV. 

INJURIES   AND   DISEASES   OE  THE   TESTICLE,   SEMINAL 
"       VESICLE,   AND   PROSTATE. 

INJURIES    AND    DISEASES    OF    THE    TESTICLE. 

Ectopic  Testicle. — Imperfect  descent  of  the  testicle  may  result  in 
its  remaining  in  the.  abdominal  cavity,  near  the  internal  abdominal 
ring,  in  the  inguinal  canal,  in  or  just  without  the  external  ring.  Under 
the  two  last  conditions  the  organ  is  usually  movable,  and  often  may 
be  drawn  upward  or  forced  downward  at  will.  In  its  normal  descent  the 
testicle  may  for  some  reason  escape  the  scrotal  pouch  and  lie  in  the 
subcutaneous  tissues  of  the  groin  or  perineum. 

Odiorne  and  Simmons,  from  a  recent  study  of  77  cases,  conclude 
that  a  retained  testicle  may  develop  normally  until  puberty,  but  if 
it  is  not  then  placed  in  the  scrotum  further  development  is  arrested 
and  the  organ  remains  functionless.  In  its  faulty  position  an  unde- 
scended testicle  may  be  the  seat  of  frequent  traumata,  which  give  rise 
to  inflammatory  attacks  and  fibrous  changes. 

Such  testicles  not  infrequently  are  the  seat  of  malignant  disease 
later  in  life.  Undescended  testicle  is  often  associated  with  congenital 
inguinal  hernia. 

Treatment. — The  treatment  of  this  condition  should,  as  a  rule,  be 
undertaken  before  puberty,  preferably  between  five  and  ten  years 
of  age,  when  an  attempt  may  be  made  to  place  the  organ  in  the  scrotum. 
In  the  inguinal,  crural,  and  perineal  varieties  this  is  often  possible. 
In  the  higher  varieties  of  undescended  testicle  this  is  impossible,  and 
the  testicle  should  be  allowed  to  remain  in  the  abdominal  cavity  or  be 
removed.  The  best  operation  for  undescended  testicle  is  that  of 
Beven  and  should  consist  in  an  incision  along  the  inguinal  canal 
extending  downward  to  the  scrotum.  The  inguinal  canal  is  opened 
as  in  the  operation  for  hernia,  and  the  upper  portion  of  the  spermatic 
cord  carefully  separated  from  the  generally  patent  funicular  process 
of  the  peritoneum  down  to  the  upper  margin  of  the  testicle.  The 
peritoneal  pouch  is  next  ligated  near  the  internal  ring  and  divided, 
and  the  redundant  portion  above  the  tunica  vaginalis  removed,  or, 
as  is  often  necessary,  the  tunica  reconstructed  bv  a  plastic  procedure. 
Traction  is  then  made  upon  the  cord  to  determine  its  length.  If  too 
short  to  allow  the  testicle  to  lie  freely  in  the  scrotum,  the  spermatic 
artery  and  veins  may  be  ligated  and  cut.  If  this  is  not  sufficient  to  allow 
the  organ  to  lie  easily  in  the  scrotal  pouch,  the  floor  of  the  inguinal 


700     DISEASES  OF  TESTICLE,  SEMINAL  VESICLE,  PROSTATE 

canal  should  be  divided  and  the  cord  transplanted  to  allow  it  to 
emerge  from  the  abdomen  near  the  pubic  spine.  This  will  give  an 
increased  length  to  the  cord  and  allow  an  inch  or  more  of  descent.  If 
the  cord  is  still  too  short,  it  may  be  separated  by  the  ringer  from  its 
intra-abdominal  attachments.  A  pocket  should  next  be  made  by 
separating  the  tissues  of  the  scrotum,  and  the  testicle  and  its  envelop- 
ing tunics  placed  within  it  and  held  by  one  or  two  catgut  purse-string 
sutures  at  the  upper  part  of  the  scrotal  sac.  The  inguinal  canal  should 
then  be  repaired  as  in  the  Bassini  operation  for  hernia  and  the  wound 
closed. 

Contusions  of  the  Testicle. — Contusions  of  the  testicle  are  of  fre- 
quent occurrence  and  result  from  a  variety  of  traumata. 

Symptoms.- — The  symptoms  are  a  severe,  sickening  pain  accom- 
panied often  by  a  grave  degree  of  shock,  evidenced  by  pallor,  weak- 
ness, cold  perspiration,  and  a  rapid,  feeble  pulse. 

Treatment. — The  treatment  should  consist  in  rest  and  hot  fomenta- 
tions to  the  injured  part.  Severe  contusions  are  occasionally  followed 
by  inflammation  and  subsequent  atrophy  of  the  organ. 

Wounds  of  the  Testicle. — Wounds  of  the  testicle  give  rise  to  much 
the  same  symptoms  as  severe  contusions,  and  in  these  cases  the  surgical 
treatment  should  always  be  carried  out  under  general  anesthesia  on 
account  of  the  severe  shock  which  frequently  accompanies  the  handling 
and  suturing  of  this  highly  sensitive  organ. 

Wounds  of  the  testicle  should  be  promptly  repaired,  under  the 
strictest  aseptic  precautions,  for  the  reason  that  a  failure  of  union 
and  infection  of  the  parts  frequently  give  rise  to  hernia  testis,  a  condi- 
tion characterized  by  protrusions  of  large  masses  of  convoluted  tubules, 
which  form  a  soft,  bleeding,  fungating  mass  requiring  castration. 

Torsion  of  the  Spermatic  Cord. — Torsion  of  the  spermatic  cord  is  a 
rare  condition  caused  by  a  twisting  of  the  cord  and  rotation  of  the 
testicle,  the  etiology  of  which  is  not  well  understood.  A  fairly  large 
proportion  of  the  cases  are  associated  with  imperfect  descent  of  the 
testicle,  and  in  a  few  instances  persistence  of  the  mesorchium  has  been 
noted.  Rotation  results  in  a  cutting  off  of  the  blood  supply,  which 
gives  rise  to  hemorrhagic  infarction  of  the  organ.  In  the  milder 
varieties  there  is  pain  in  the  testicle  of  a  sickening  character,  with 
nausea  and  evidences  of  shock.  In  the  severe  forms  the  vessels  may  be 
so  strangulated  as  to  give  rise  to  gangrene  of  the  organ.  In  these 
cases  there  is  generally  to  be  felt  an  indurated  swelling  at  the  seat 
of  the  twist,  above  the  testicle,  which  is  tender  to  the  touch. 

If  the  condition  cannot  be  relieved  by  manipulation,  open  operation 
is  to  be  advised  with  a  view  to  reducing  the  displacement  or  removing 
the  gangrenous  testicle. 

Acute  Epididymitis. — Acute  epididymitis  is  an  inflammation  of  the 
epididymis,  caused  in  the  great  majority  of  cases  by  extension  of  a 
gonorrheal  process  from  the  urethra.  This  complication  is  practically 
always  preceded  by  the  occurrence  of  a  posterior  urethritis,  and  the 


INJURIES  AXD   DISEASES  OF   THE  TESTICLE  701 

process  may  extend  from  the  posterior  urethra  along  the  ejaculate  in- 
ducts and  vasa  deferentia,  or  by  the  lymphatics  to  the  epididymis.  It 
may  occur  at  any  period  in  the  disease,  but  is  rare  before  the  second 
week.  The  disease  also  may  arise  from  infection  occasioned  by  the 
passage  of  unclean  urethral  instruments,  or  from  an  acute  inflamma- 
tory focus  in  the  prostate  or  seminal  vesicle. 

Symptoms. — The  symptoms  are  pain  and  tenderness  in  the  region 
of  the  testicle,  and  the  rapid  formation  of  an  indurated  mass  occupy- 
ing the  position  of  the  epididymis  and  partly  surrounding  the  testicle, 
which,  as  a  rule,  is  not  involved  in  the  process. 

The  swelling  may  reach  the  size  of  a  small  orange,  is  accompanied 
by  redness  and  edema  of  the  scrotum,  and  is  exquisitely  tender.  A 
certain  amount  of  fluid  frequently  is  present  in  the  cavity  of  the  tunica 
vaginalis.  In  certain  instances  pain  and  tenderness  in  the  groin  over 
the  region  of  the  spermatic  cord  precede  the  development  of  symptoms 
in  the  scrotum.  In  these  cases  the  vas  deferens  can  be  felt  as  a  thick- 
ened tender  cord  at  or  just  below  the  external  abdominal  ring.  The 
symptoms  develop  quickly,  the  scrotal  tumor  often  doubling  in  size 
in  twenty-four  hours.  There  are  fever,  headache,  malaise,  and  occa- 
sionally chills  at  the  outset.  Xot  infrequently  there  is  marked  diminu- 
tion of  the  urethral  discharge.  These  symptoms  continue  without 
abatement  for  several  days;  the  pain  and  tenderness  then  gradually 
subside  and  the  swelling  slowly  disappears.  A  small  hard  nodule 
often  persists  in  the  head  or  tail  of  the  epididymis  for  months 
or  years,  which  may  completely  occlude  the  lumen  of  the  vas,  and, 
if  double,  give  rise  to  sterility.  Double  epididymitis,  however,  is 
comparatively  rare. 

Treatment. — As  in  other  acute  and  painful  inflammatory  processes, 
it  is  desirable  at  the  outset  to  empty  the  bowels  and  insure  absolute 
rest  for  the  part.  Calomel  and  salts,  followed  by  rest  in  bed,  are 
therefore  to  be  advised  in  the  beginning  of  the  attack.  Elevation  of 
the  scrotum  by  means  of  a  folded  towel  or  a  broad  strip  of  adhesive 
plaster  placed  beneath  the  scrotum  and  extending  from  one  thigh  to 
the  other  will  often  relieve  the  dragging  pain,  and  the  application  of 
heat  by  means  of  fomentations  or  flax-seed  poultices,  will  afford 
additional  comfort.  In  certain  cases  where  the  pain  is  severe  and  not 
relieved  by  these  measures,  aspiration  of  the  fluid  in  the  cavity  of 
the  tunica  vaginalis  (acute  hydrocele)  will  give  relief.  In  more  severe 
cases  Hagner  has  recommended  freely  opening  the  cavity  of  the  tunica 
vaginalis  and  making  multiple  punctures  through  the  fibrous  sheath 
of  the  inflamed  epididymis. 

For  obvious  reasons,  treatment  by  rest  in  bed  is  impracticable  in 
many  cases.  In  these  the  application  of  10  per  cent,  guaiacol  ointment 
and  the  use  of  a  suspensory  bandage  will  be  found  beneficial.  When 
the  pain  is  acute  and  not  relieved  by  the  ordinary  means,  lightly 
touching  the  surface  of  the  scrotum  with  the  white-hot  cautery  point, 
as  recommended  by  Halsted,  will  occasionally  relieve  the  pain  and 


702     DISEASES  OF  TESTICLE,  SEMINAL  VESICLE,  PROSTATE 

enable  a  previously  bedridden  patient  to  be  up  and  about.  The  use  of 
the  dry  poultice  was  recommended  by  the  writer  in  1891,  especially 
for  absorption  of  the  indurations  which  frequently  persist  for  a  long 
period  after  the  acute  symptoms  have  passed.  This  dressing  consists 
in  a  moderately  thick  layer  of  cotton  applied  over  the  inflamed  half 
of  the  scrotum.  This  is  covered  by  a  layer  of  rubber  protective  tissue 
so  fashioned  that  it  completely  encloses  the  diseased  area,  with  its 
edges  extending  on  to  the  healthy  skin  of  the  scrotum  in  a  manner 
partly  to  overlap  but  not  entirely  enclose  the  healthy  side.  This  is 
secured  by  a  snugly  applied  gauze  bandage,  and  the  whole  held  in  place 
by  a  suspensory.  This  dressing,  by  retaining  heat  and  preventing 
absorption  of  the  moisture  abundantly  supplied  by  the  sweat-glands, 
possesses  all  the  advantages  of  a  flax-seed  poultice,  and  in  addition, 
exerts  moderate  compression,  insures  suspension,  and  allows  the 
patient  to  be  up  and  about. 

Inunctions  of  mercurial  ointment  and  strapping  the  testicle  are 
occasionally  employed  to  promote  absorption  of  the  exudate  in  chronic 
cases.  For  the  sterility  caused  by  the  presence  of  indurated  masses 
in  the  globus  minor  of  the  epididymis  Martin  recommends  epididymo- 
vasostomy,  or  anastamosing  the  vas  deferens  into  one  of  the  tubules 
of  the  globus  major.  Both  Martin  and  Hagner  have  reported  success- 
ful cases  in  which  repeated  examinations  had  failed  to  find  motile 
spermatozoa  in  the  seminal  fluid  before  operation,\vhile  after  operation 
they  are  present  in  large  numbers.  In  several  instances  also  a  pregnancy 
has  followed. 

Orchitis. — Orchitis  is  an  inflammation  of  the  testicle,  caused  gener- 
ally by  trauma,  occasionally  by  septic  infection  of  the  deep  urethra,  or 
metastases  from  mumps  or  other  infectious  diseases.  In  these  cases 
the  inflammatory  process  is  limited  to  the  tissues  of  the  testicle  proper, 
the  epididymis  not  being  involved.  The  term  orcho-epididymitis  is 
applied  to  those  inflammations  which  involve  both  the  testicle  and 
epididymis. 

Symptoms. — The  symptoms  are  pain  of  a  severe  and  often  'of  a 
sickening  character,  extending  from  the  scrotum  to  the  groin  and  back, 
swelling,  and  great  tenderness  of  the  organ.  If  the  swelling  can  be 
palpated  carefully,  it  will  be  found  to  be  globular  in  shape  rather  than 
semilunar,  as  in  the  case  of  epididymitis. 

Accompanying  the  local  symptoms  there  are  fever,  general  weak- 
ness, and  often  nausea  and  vomiting.  If  the  disease  is  due  to  infection 
with  pyogenic  organisms,  the  process  may  go  on  to  suppurat  on.  In 
the  majority  of  instances,  however,  resolution  takes  place,  followed  in 
many  cases  by  atrophy  of  the  organ. 

Treatment. — The  treatment  is  the  same  as  for  epididymitis. 

Syphilitic  Testicle.— Syphilis  may  affect  either  the  epididymis  or 
the  testicle.  Syphilitic  epididymitis  is  rare;  it  occurs  in  the  secondary 
or  tertiary  stage,  and  begins  usually  in  the  globus  major,  differing 
thereby  from  the  gonorrheal  and  tuberculous  affections,  which  usually 


INJURIES   AND   DISEASES  OF   THE   TESTICLE  703 

have  their  origin  in  the  globus  minor.  The  disease  spreads  to  the 
other  portions  of  the  epididymis,  and  may  be  accompanied  by  an 
effusion  of  serum  into  the  tunica  vaginalis.  It  is  often  bilateral.  As 
a  rule,  there  is  little  or  no  pain,  and  the  organ  is  not  sensitive  to  press- 
ure. In  syphilitic  orchitis,  which  is  a  more  common  affection,  the 
disease  generally  occurs  in  the  late  secondary  or  tertiary  stage.  It  may 
be  diffuse  or  circumscribed.  In  the  diffuse  variety  there  is  an  oxer- 
growth  of  the  connective-tissue  framework  and  fibrous  tunic,  giving 
rise  to  a  symmetric  enlargement  of  the  gland.  In  the  circumscribed 
variety  there  is  a  gummatous  infiltration  of  a  part  only  of  the  gland, 
forming  an  irregular  enlargement  or  globular  tumor.  The  former 
variety  causes  a  painless  enlargement  which  may  persist  for  years 
(syphilitic  sarcocele),  or  finally  disappear  and  cause  atrophy  of  the 
organ;  the  latter,  or  .gummatous  variety  if  untreated  may  break  down 
and  suppurate. 

Diagnosis. — Gonorrheal  epididymitis  is  easily  distinguished  from 
the  syphilitic  variety  by  the  rapidity  of  the  process,  the  occurrence  of 
acute  pain,  and  the  size  of  the  enlargement.  The  differential  diagnosis 
between  tuberculous  and  syphilitic  epididymitis  is  more  difficult. 
In  the  tuberculous  affection  the  process  generally  begins  in  the  tail  of 
the  epididymis;  it  progresses  more  slowly  than  the  syphilitic  form,  it 
practically  always  invades  the  vas  deferens,  often  the  seminal  vesicle 
and  prostate.  The  disease  frequently  follows  the  gonorrheal  variety. 
The  testicle  itself  is  rarely  involved  except  secondarily.  In  syphilitic 
epididymitis  the  globus  major  is  usually  the  part  first  affected.  When 
the  entire  epididymis  is  involved,  there  is  nothing  in  the  feeling  of  the 
mass  to  distinguish  it  from  either  the  tuberculous  or  chronic  gonorrheal 
form  of  the  disease.  The  chief  characteristics,  however,  are  that  the 
growth  is  practically  painless,  is  comparatively  insensitive  to  pressure, 
and  that  it  never  involves  the  cord,  seminal  vesicle  or  prostate.  Syphil- 
itic orchitis  is  far  more  common  than  syphilitic  epididymitis.  It 
presents  itself  as  a  painless  circumscribed  or  diffuse  swelling  of  the 
organ,  which  is  prone  to  gummatous  degeneration,  softening,  and 
abscess-formation.  A  positive  Wassermann  reaction  may  help  in 
diagnosis  in  an  otherwise  obscure  condition. 

Treatment. — Early  syphilitic  epididymitis  requires  no  treatment 
other  than  that  addressed  to  the  constitutional  condition.  In  the 
later  affections,  potassium  iodide  should  be  given  in  large  doses,  also 
mercury  in  the  form  of  inunction  or  vapor  baths,  and  locally  by  means 
of  the  constant  application  of  mercurial  ointment  to  the  diseased 
testicle. 

In  all  forms  except  the  chronic  fibrous  interstitial  orchitis  the 
prognosis  under  intelligent  treatment  is  favorable. 

Tuberculosis  of  the  Testicle. — This  disease  occurs  as  a  chronic,  slowly 
progressing  induration  and  enlargement  of  the  epididymis.  In  the 
majority  of  instances  the  globus  minor  is  the  part  first  affected,  and 
early  appearance  of  the  disease  in  this  locality  may  differ  in  no  respect 


704     DISEASES  OF  TESTICLE,  SEMI  SAL  VESICLE,  PROSTATE 

from  the  chronic  enlargements  sometimes  persisting  after  a  gonorrheal 
epididymitis.  In  fact,  tuberculosis  is  frequently  engrafted  upon  such 
a  focus.  As  the  disease  spreads  it  next  involves  the  cord,  then  the 
remaining  portions  of  the  epididymis,  the  seminal  vesicle,  and  prostate, 
and  finally  it  invades  the  testicle  proper.  If  the  resistance  of  the 
individual  is  considerable  and  he  lives  amid  favorable  hygienic  sur- 
roundings, the  progress  is  often  exceedingly  slow,  and  the  primary 
nodule  may  remain  stationary  for  months  or  years.  Under  less 
favorable  conditions  the  process  may  extend  rapidly  and  be  associated 
with  evidences  of  tuberculosis  in  other  organs.  In  these  cases 
the  tuberculous  nodules  soften  early,  become  adherent  to  the  tissues 
of  the  scrotum,  and  eventually  rupture  and  discharge,  leaving  one  or 
more  sinuses,  and  occasionally  a  hernia  testis. 

Diagnosis. — In  the  early  stages  of  a  tuberculous  epididymitis  there 
may  be  no  symptoms  other  than  the  presence  of  a  small  area  of  indura- 
tion in  the  epididymis.  In  other  cases  there  are  localized  pain  and 
discomfort,  and  a  dragging  sensation.  Tenderness  may  exist,  and  occa- 
sionally is  well  marked.  When  the  entire  epididymis  is  involved,  it 
can  be  felt  as  a  dense  nodular  semilunar  mass  moulded  over  the 
posterior  border  of  the  testicle,  and  separated  from  it  by  a  distinct  sul- 
cus. The  cord  generally  can  be  felt  to  be  thickened  and  nodular, 
somewhat  suggesting  the  feeling  of  a  string  of  beads.  When  the 
process  involves  the  testicle,  this  organ  enlarges,  and  later  presents 
on  its  surface  areas  of  softening  which  may  suppurate  and  discharge 
a  curdy  pus. 

For  a  differential  diagnosis  between  gonorrheal,  tuberculous,  and 
syphilitic  disease  of  the  testicle,  see  page  703. 

Treatment. — In  the  earlier  stages  these  cases  are  frequently  much 
benefited  by  a  change  of  air.  Living  in  a  mountainous  district,  espe- 
cially if  surrounded  by  pines,  will  often  arrest  the  progress  of  the 
disease.  When  this  is  impracticable,  cod-liver  oil,  iron,  arsenic,  and 
a  highly  nutritious  diet  will  often  prove  of  benefit.  The  early  removal 
by  surgical  means  of  a  localized  tuberculous  focus  when  limited  to  the 
epididymis  or  testicle  is,  however,  the  best  treatment,  and  should  be 
advised  whenever  the  disease  is  thus  limited. 

Undoubtedly  castration  is  the  safest  and  surest  means  of  removing 
such  a  focus.  The  propriety  of  removing  a  diseased  epididymis  only, 
in  a  case  in  which  there  is  no  involvement  either  of  the  cord  or  of  the 
testicle,  has  been  largely  discussed  of  late  by  the  profession ;  and  while 
such  a  procedure  might  be  advisable  under  such  conditions,  the  oppor- 
tunities for  carrying  out  this  plan  are  exceedingly  rare,  for  in  the 
majority  of  instances  when  the  parts  are  exposed  the  disease  is  found 
to  involve  the  mediastinum  testis  or  the  visceral  layer  of  the  tunica 
vaginalis. 

If  the  cord  is  extensively  involved,  and  especially  if  there  is  evidence 
of  disease  of  the  seminal  vesicle,  all  of  these  structures  should  be 
removed. 


TUMORS  OF  THE  TESTICLE  705 

Removal  of  a  painful  and  disorganized  testicle  in  the  presence  of 
extensive  tuberculous  disease  elsewhere  occasionally  may  be  justifiable 
for  the  relief  of  suffering. 

TUMORS    OF    THE    TESTICLE. 

While  the  subject  of  tumors  of  the  testicle  has  been  surrounded 
by  much  confusion,  recent  investigations  have  led  to  the  belief  that 
most  of  the  solid  tumors  occurring  in  the  testicle  arise  from  embryonic 
rests  which  may  be  of  exceedingly  complex  structure. 

Thus  we  have  the  slow-growing  teratomata,  which  are  composed  of 
fibrous  tissue,  glandular  and  muscular  elements,  cartilage,  myxoma- 
tous material,  etc.,  the  so-called  mixed  tumors  of  the  testicle.  These, 
as  a  rule,  are  innocent  growths,  may  reach  a  certain  size,  and  then 
remain  stationary  for  years.  At  a  later  period,  however,  these  tumors 
may  take  on  a  malignant  character,  grow  rapidly,  develop  metastases, 
produce  cachexia  and  death.  Carcinoma  of  the  testicle  occurs  in 
both  the  alveolar  type  and  the  diffuse,  rapidly  growing  cellular  variety. 
Sarcoma  is,  perhaps,  more  frequently  encountered  than  carcinoma. 
It  occurs  in  the  slow-growing,  hard,  fibrous  variety,  or  as  a  diffuse, 
rapidly  growing,  cellular  tumor,  which  closely  resembles  the  soft, 
cellular  carcinomatous  growth. 

Ewing,  who  has  given  much  attention  to  these  tumors,  is  of  the 
opinion  that  most  of  them  arise  from  embryonal  rests  made  up  of  the 
various  tissues  found  in  the  innocent  teratomata,  but  that  a  lawless 
proliferation  occurs  in  one  of  the  many  tissues  present,  which  may 
grow  rapidly  and  obscure  the  other  elements  of  the  original  focus. 

This  view  was  suggested  by  the  finding  of  a  small  focus  of  complex 
teratomatous  elements  in  a  tumor  which,  in  other  respects,  presented 
the  gross  and  histologic  picture  of  a  diffuse  cellular  carcinoma;  and 
also  by  the  fact  that,  in  malignant  degeneration  of  a  teratoma,  one 
occasionally  can  find  both  carcinomatous  and  sarcomatous  areas,  with 
evidence  of  metastasis,  both  by  the  bloodvessels  and  lymphatics. 

In  a  few  recorded  cases  more  or  less  typical  chorion  epithelioma  has 
been  reported  in  a  testicular  tumor. 

A  class  of  tumors  has  been  described  by  Bland-Sutton  and  others 
as  arising  from  the  paradidymis.  They  may  appear  as  single  cysts, 
generally  small,  occurring  near  the  globus  major  of  the  epididymis,  and 
often  containing  a  milky  fluid  (spermatoceles),  or  as  larger  masses  made 
up  of  numerous  communicating  cysts,  sometimes  with  intracystic 
growths.  These  tumors  may  reach  a  large  size  and  may  compress  the 
testicle.  They  are  commonly  spoken  of  as  adenomata  or  as  fibrocystic 
disease  of  the  testicle,  and,  as  a  rule,  are  innocent. 

Diagnosis. — Subjective  symptoms  are  not  marked  in  tumors  of  the 

testicle.    Pain  is  rarely  present  except  in  the  later  stages  of  the  more 

malignant  growths.     The  presence  of  an  enlargement  of  the  organ 

and  a  sense  of  weight  and  dragging  are  all  that  is  complained  of  by  the 

45 


706     DISEASES  OF  TESTICLE,  SEMINAL  VESICLE,  PROSTATE 

patient.  The  cellular  carcinomata  and  sarcomata  are,  as  a  rule,  easily 
recognized  by  their  rapid  growth  and  soft  or  elastic  consistence;  the 
fibrosarcomata,  by  their  slow  growth,  their  hardness,  and  the  smooth, 
regular  outline  of  their  surface;  the  mixed  tumors,  by  their  irregular 
outlines  and  uneven  consistence;  the  cysts  by  their  oval  shape  and 
their  elasticity.    In  many  cases  the  diagnosis  cannot  be  made  clinically. 

Prognosis. — In  malignant  disease  of  the  testicle  the  prognosis  is 
generally  unfavorable,  chiefly  for  the  reason  that  the  growth  does 
not  give  rise,  in  its  early  development,  to  painful  symptoms.  In 
the  carcinomata  and,  to  a  certain  extent,  in  the  sarcomata,  lymph- 
node  metastasis  takes  place  early  and  in  an  inaccessible  position; 
for  Most  has  shown  that  the  lymphatics  from  the  testicle  pass  upward 
with  the  spermatic  vessels  and  enter  nodes  surrounding  the  aorta  and 
vena  cava  just  below  the  renal  vessels.  In  this  locality  they  are 
covered  by  the  peritoneum  and  root  of  the  mesentery,  making  their 
surgical  removal  impracticable.  Legueu  has  recently  reported  a  series 
of  100  cases  of  malignant  disease  of  the  testicle  with  19  cured  after 
three  years. 

Treatment. — With  the  exception  of  the  small  cysts  which  appear  in 
the  neighborhood  of  the  head  of  the  epididymis,  all  tumors  of  the 
testicle  should  be  removed  at  the  earliest  possible  moment,  for  the 
reason  that  the  majority  are  genuinely  malignant  and  nearly  all 
have  a  potential  malignancy.  Castration  with  removal  of  all  affected 
portions  of  the  scrotum  and  adjacent  lymphatics  is  the  operation  of 
choice. 

DISEASES    OF    THE    SEMINAL   VESICLE. 

Seminal  Vesiculitis. — Seminal  vesiculitis  is  an  inflammation  of  the 
seminal  vesicle  and  ampulla  of  the  vas  deferens,  caused  in  the  majority 
of  instances  by  the  extension  upward  of  a  gonorrheal  infection  of  the 
urethra  through  the  ejaculatory  duct.  Other  infections  of  the  seminal 
vesicles  are  occasionally  observed.  In  these  cases  the  inflammation 
is  generally  preceded  by  a  condition  of  atony  of  the  muscular  walls, 
giving  rise  to  retention  of  the  secretions.  This  is  usually  the  result  of 
sexual  excesses,  especially  in  early  life. 

Symptoms. — The  symptoms  of  an  acute  seminal  vesiculitis  are  often 
obscure.  There  may  be  pain  deeply  seated  in  the  perineum  or  rectum, 
bladder  irritability,  and  sexual  disturbances,  evidenced  by  frequent 
erections  and  painful  ejaculations.  In  other  cases  subjective  symp- 
toms are  absent,  and  the  diagnosis  can  only  be  made  by  feeling  on 
rectal  examination  a  soft,  boggy,  elongated,  tender  body  in  the  posi- 
tion of  the  vesicle.  Occasionally  in  mixed  infections  an  abscess  may 
develop  in  and  about  the  vesicle,  giving  rise  to  severe  throbbing  pain, 
fever,  chills,  and  marked  tenderness  on  palpation.  Unless  relieved 
surgically,  the  abscess  will  generally  rupture  into  the  rectum,  exception- 
ally into  the  bladder,  very  rarely  in  both  directions,  causing  a  vesico- 
rectal fistula,  a  condition  giving  rise  to  great  suffering,  and  presenting 


DISEASES  OF  THE  SEMINAL    VESICLE  707 

for  its  successful  treatment  an  extremely  difficult  surgical  problem. 
Iu  chronic  vesiculitis  the  symptoms  are  often  only  those  of  sexual 
neurasthenia,  although  in  the  majority  of  instances  there  are  lumbar 
pains,  rectal  discomfort,  and  often  an  irritable  bladder  from  an  exten- 
sion of  the  process  to  the  trigone.  The  condition  is  important,  how- 
ever, on  account  of  the  frequent  reinfections  of  the  urethra  which 
occur  during  its  progress.  Fuller,  who  was  the  first  to  study  this 
condition  carefully  and  to  appreciate  its  clinical  importance,  has  de- 
monstrated that  many  neglected  and  supposed  incurable  cases  of 
chronic  urethritis  may  be  cured  by  relief  of  the  vesicular  disease.  This 
author  has  also  called  attention  to  the  fact  that  a  chronic  vesiculitis  is 
perhaps  the  most  important  etiologic  factor  in  chronic  arthritis, 
not  only  of  the  gonorrheal  type  but  also  other  varieties;  and  Billings 
has  expressed  the  belief  that  many  cases  of  arthritis  deformans  are  due 
to  a  chronic  infection  of  the  vesicles  by  the  streptococcus. 

Ureteral  stricture  and  occlusion  occasionally  result  from  an  exten- 
sion of  the  disease  to  the  lower  portion  of  the  ureter.  The  author, 
on  one  occasion,  encountered  such  a  condition  in  which  calcification 
of  the  inflammatory  exudate  gave  an  .r-ray  shadow  resembling  a 
ureteral  calculus.  Division  of  the  ureter  above  the  stricture  and 
vesical  implantation,  however,  brought  about  a  cure. 

Treatment. — In  the  acute  stages  the  pain  and  perineal  discomfort 
often  may  be  relieved  by  hot  rectal  irrigations;  gently  stripping  the 
vesicle  with  the  finger  in  the  rectum,  and  emptying  it  of  its  contents 
at  regular  intervals  and  treatment  addressed  to  the  urethral  infection 
will  generally  bring  about  a  cure.  In  the  extremely  chronic  cases 
which  resist  this  simple  treatment,  Fuller  recommends  exposure  of  the 
vesicle,  with  incision  and  drainage.  By  this  operation  he  has  suc- 
ceeded not  only  in  relieving  the  local  symptoms,  but  on  several  occa- 
sions has  been  able  to  rid  his  patient  of  a  chronic  sepsis,  evidenced  by 
obstinate  and  recurring  gonorrheal  arthritis  and  other  symptoms  of 
chronic  toxemia. 

Tuberculosis  of  the  Seminal  Vesicle. — The  seminal  vesicle  is  occa- 
sionally the  seat  of  a  primary  tuberculous  focus,  the  infection  reaching 
the  part  by  the  blood  current.  It  may  also  occur  secondarily  from 
extension  upward  of  a  tuberculous  infection  from  the  testicle,  or 
extension  backward  of  an  infection  from  the  prostatic  urethra. 

Symptoms. — In  the  earlier  stages  the  process  rarely  gives  rise  to 
subjective  sensations.  At  a  later  period  there  may  be  pain  referred 
to  the  rectum  or  neck  of  the  bladder,  with  frequency  of  micturition, 
vesical  tenesmus,  and  sexual  disturbances.  On  examination  by  rectal 
palpation,  the  finger  detects  a  firm  circumscribed  induration  of  the 
vesicle  clearly  contrasting  with  the  soft,  boggy  feel  of  the  organ  when 
the  seat  of  a  gonorrheal  infection. 

As  in  other  parts  of  the  genito-urinary  tract,  a  latent  tuberculous 
focus  is  often  awakened  into  activity  by  the  occurrence  of  a  gonorrheal 
infection. 


708     DISEASES  OF  TESTICLE,  SEMINAL  VESICLE,  PROSTATE 

Treatment. — When  the  disease  is  clearly  limited  to  the  vesicle  the 
treatment  should  be  operative,  and  the  disease  radically  removed.  In 
other  cases  the  treatment  should  be  hygienic  and  supporting. 


DISEASES    OF    THE    PROSTATE    GLAND. 

Acute  Prostatitis. — Acute  prostatitis  is  an  inflammation  of  the  pros- 
tate gland,  caused  in  the  majority  of  instances  by  the  backward  exten- 
sion of  a  gonorrheal  process  from  the  urethra,  or  from  an  infection  con- 
veyed to  the  organ  by  the  use  of  urethral  instruments.  The  process 
varies  in  intensity  from  the  slight  transitory  congestion  and  swelling 
of  the  gland  which  frequently  accompanies  a  posterior  urethritis,  to  an 
acute  suppurative  process  which  may  destroy  its  entire  structure.  The 
infection  reaches  the  prostate  by  direct  extension  of  the  inflammatory 
process  from  the  urethral  mucous  membrane  to  the  prostatic  glands, 
large  numbers  of  which  open  upon  the  floor  of  the  canal.  The  mucous 
membrane  lining  the  ducts  of  these  glands  becomes  thickened,  often 
occluding  their  orifices  and  retaining  the  infected  secretions.  This  gives 
rise  to  a  perifollicular  inflammation,  which  may  cause  numerous  indu- 
rated areas  to  appear  throughout  the  gland,  with  more  or  less  congestion 
and  enlargement  of  the  organ.  One  or  more  of  these  may  suppurate  and 
discharge  into  the  urethra,  or  resolution  may  take  place  without  sup- 
puration. This  condition  is  described  as  follicular  prostatitis.  In 
severer  cases  these  perifollicular  indurations  may  extend  rapidly  and 
eventually  involve  the  entire  structure  of  the  gland,  which  becomes 
greatly  enlarged,  hot,  and  tender.  One  or  more  foci  of  suppuration  may 
appear,  which  usually  coalesce,  forming  a  single  large  abscess  cavity. 
To  this  condition  the  terms  diffuse  or  suppurative  prostatitis  have  been 
applied. 

Diagnosis. — In  the  acute  form  of  the  disease  the  process  is  preceded 
by  symptoms  of  a  posterior  urethritis:  frequent  and  painful  micturi- 
tion, vesical  tenesmus,  and  pyuria.  To  these  symptoms  there  are 
added  a  slight  elevation  of  temperature  and  constant  pain  in  the 
rectum  and  perineum.  In  severer  cases  there  may  be  chills,  high 
fever,  and  retention  of  urine  from  pressure  of  the  swollen  gland.  Rectal 
examination  is  always  necessary  to  establish  the  diagnosis,  as  all  of  the 
preceding  symptoms  may  be  present  under  other  conditions.  In  the 
acute  follicular  variety  of  the  disease  the  examining  finger  will  feel  the 
prostate  somewhat  swollen  and  tender,  and  studded  with  several  small 
oval  areas  of  induration.  In  the  diffuse  form  the  gland  is  symmetric- 
ally enlarged,  sometimes  to  the  size  of  a  large  orange,  almost  completely 
filling  the  pelvic  cavity.  It  is  hot,  indurated,  pulsating,  and  exceed- 
ingly tender.  In  the  acute  congestions  which  sometimes  accompany 
a  posterior  urethritis  there  is  also  considerable  swelling,  but  less 
tenderness  on  pressure,  and  the  gland  feels  elastic  rather  than  densely 
indurated. 


DISEASES  OF  THE  PROSTATE  GLAND  709 

When  suppuration  occurs  there  is  often  retention  of  urine.  There 
may  be  chills,  throbbing  pain,  and  increased  fever;  but  these  are  not 
constant,  as  large  abscesses  are  not  infrequently  encountered  in 
individuals  without  fever  or  other  constitutional  evidences  of  sup- 
puration. There  is  generally,  however,  a  marked  leukocytosis.  Fluc- 
tuation occasionally  may  be  detected  by  rectal  palpation.  In  some 
cases  in  which  the  abscess  is  small  its  seat  often  can  be  located  by  feeling 
an  area  of  increased  tenderness,  and  induration  in  some  part  of  the 
gland.  In  untreated  cases,  rupture  of  the  abscess  generally  takes 
place  into  the  urethra,  either  spontaneously  or  as  a  result  of  the 
passage  of  an  instrument  for  relief  of  the  retention,  and  in  the  majority 
of  instances  is  followed  by  recovery.  Rupture  into  the  rectum  is  less 
frequent,  and  recovery  is  slower  and  less  certain.  Rupture  into  the 
ischiorectal  fossa  and  eventually  into  the  perineal  region  is  exceedingly 
rare.  If  the  abscess  ruptures  posteriorly,  the  pus  may  burrow  exten- 
sively beneath  the  rectovesical  fascia,  giving  rise  to  an  extensive  pelvic 
abscess  and  symptoms  of  grave  sepsis.  It  occasionally  happens  that 
rupture  takes  place  both  into  the  urethra  and  rectum,  creating  a  recto- 
urethral  fistula,  which  occasions  great  suffering  and  is  repaired  with 
difficulty. 

The  deep  pelvic  lymph  nodes  may  very  rarely  suppurate  as  a  result 
of  infection  carried  to  them  from  an  abscess  of  the  prostate  gland. 
In  these  cases  there  are  evidences  of  grave  sepsis,  which  do  not  dis- 
appear after  evacuation  of  the  prostatic  focus.  A  continued  leukocy- 
tosis, indefinite  pain  and  discomfort  in  the  lower  part  of  the  abdomen 
and  in  the  rectum,  are  the  only  symptoms.  The  abscess  thus  formed 
may  eventually  point  toward  the  posterior  rectal  wall. 

Treatment. — In  the  early  stages  of  the  disease  the  patient  should 
remain  in  bed  and  the  bowels  be  freely  moved  by  calomel  and  salines. 
Hot  rectal  irrigation  by  means  of  the  Kemp  tube  should  be  practised 
every  five  or  six  hours,  and  suppositories  of  opium  or  morphine  and 
belladonna  administered  if  the  vesical  tenderness  and  pain  are  severe. 
In  the  follicular  form  of  the  disease  measures  should  also  be  employed 
to  allay  the  posterior  urethritis,  as  deep  injections  of  protargol  or  silver 
nitrate,  and  irrigations  with  mild  solutions  of  potassium  permanganate. 
In  the  majority  of  instances  under  this  method  of  treatment  resolution 
will  occur  and  suppuration  be  avoided.  Relief  of  pain  and  a  lowering 
of  the  temperature  do  not,  however,  necessarily  mean  that  suppura- 
tion has  not  taken  place.  ^Yhen  these  occur  without  diminution  in  the 
size  of  the'glandular  swelling,  and  when  there  is  a  marked  leukocytosis, 
an  abscess  is  probably  present,  and  should  be  sought  for  by  an  explora- 
tory operation  and  drained  through  the  perineum.  Alexander  advises 
the  performance  of  an  external  urethrotomy,  introducing  the  finger 
into  the  posterior  urethra  and  rupturing  the  abscess  into  the  canal 
by  digital  pressure.  The  author's  plan  is  to  expose  the  prostate  by  a 
perineal  incision,  as  in  the  operation  for  prostatectomy;  locate  the 
pus  by  an  exploring  needle,  then  incise,  and  drain  with  a  soft-rubber 


710     DISEASES  OF  TESTICLE,  SEMINAL  VESICLE,  PROSTATE 

tube.  It  is  occasionally  necessary  to  open  both  lateral  lobes  in  this 
maimer. 

Chronic  Prostatitis.  Chronic  prostatitis  is  a  condition  frequently 
following  the  acute  form  of  the  disease,  or  occurring  during  the  course 
of  a  protracted  posterior  urethral  inflammation.  In  the  first  class 
there  may  be  an  open  cavity  resulting  from  the  rupture  of  a  large 
abscess,  which  fills  up  from  time  to  time,  causing  subacute  symptoms, 
and  then  ruptures  and  remains  quiescent  for  a  long  period.  The 
cavity  may  contain  av  calculus,  or  its  interior  may  be  incrusted  by 
phosphatic  salts.  In  the  follicular  variety,  which  is  usually  gonor- 
rheal in  origin,  there  may  be  infection  of  one  or  more  follicles,  which 
are  not  occluded,  but  which  furnish  a  secretion  constantly  reinfecting 
the  urethral  mucous  membrane. 

Symptoms. — The  symptoms  of  this  condition  are  extremely  variable. 
Pain,  frequency  in  micturition,  vesical  and  rectal  tenesmus,  may  be 
present;  also  an  obstinate  gleet,  with  tripper  faden  and  free  pus  in 
the  urine.    Bacteriuria  may  be  the  only  symptom  in  some  cases. 

Treatment. — The  treatment  of  chronic  prostatitis  consists  in  meas- 
ures to  relieve  the  chronic  urethral  inflammation  upon  which  it  depends, 
as  irrigations,  deep  instillations  of  silver  nitrate  or  protargol,  together 
with  general  and  sexual  hygiene.  Regular  massage  of  the  prostate  is 
to  be  recommended  in  cases  of  chronic  follicular  prostatitis  in  addition 
to  the  above  measures. 

Tuberculosis  of  the  Prostate. — Tuberculosis  of  the  prostate  may 
occur  as  a  primary  disease,  but  generally  is  associated  with  tuberculosis 
of  the  testicles,  seminal  vesicles,  or  bladder. 

Symptoms. — The  symptoms  are  those  of  prostatic  and  bladder  irri- 
tation, generally  progressive  in  character,  and  not  dependent  upon 
previous  urethral  disease. 

Treatment. — The  treatment  is  unsatisfactory,  as  palliative  meas- 
ures only  can  be  adopted  in  the  majority  of  instances.  If,  however,  it 
can  be  demonstrated  that  a  primary  focus  exists  in  the  prostate, 
prostatectomy  is  indicated. 

Prostatic  Calculi. — Calculi  occasionally  develop  in  the  crypts  of  the 
prostate  gland,  and  are  caused  by  calcification  of  the  corpora  amylacea. 
They  are  small  oval  bodies  of  a  light  yellow  or  brown  color,  and  are 
generally  highly  polished. 

Their  presence  in  the  prostate  may  cause  no  disturbance.  If  the 
cavities  which  contain  them  become  infected,  suppuration  may  occur, 
giving  rise  to  symptoms  of  acute  prostatitis.  They  are  occasionally 
discharged  by  way  of  the  urethra  or  may  become  lodged  behind 
a  stricture  and  give  rise  to  retention.  They  should  be  removed 
surgically. 

Senile  Hypertrophy  of  the  Prostate. — Enlargement  of  the  prostate 
gland  occurs  in  about  one-third  of  all  men  after  fifty.  In  a  small 
number  of  these  the  enlargement  is  of  such  a  character  as  to  interfere 
with  the  function  of  urination.    The  causes  of  prostatic  overgrowth 


DISEASES  OF  THE  PROSTATE  GLAND  711 

are  not  well  understood,  but  it  is  probable  that  the  chronic  congestion 
which  accompanies  sexual  abuses  in  early  life  and  the  inflammatory 
changes  which  occur  in  the  gland  as  a  result  of  early  gonorrheal 
infection  play  some  part  in  its  production. 

Any  or  all  of  the  anatomic  structures  which  enter  into  the  for- 
mation of  the  organ  may  partake  in  the  process;  thus  we  may  have  a 
general  hypertrophy  of  the  fibrous  and  muscular  framework  of  the 
gland  giving  rise  to  a  symmetric  enlargement  of  the  organ,  or  a  local- 
ized hypertrophy  of  these  structures,  resulting  in  a  unilateral  enlarge- 
ment or  outgrowth.  Distinctly  circumscribed  tumors  are  present  in 
more  than  half  the  cases,  which  may  be  made  up  of  the  glandular  ele- 
ments (pure  adenomata),  or  of  the  muscular  and  fibrous  structures 
(fibromyomata),  similar  to  those  observed  in  the  uterus. 

Symmetric  enlargements  produce,  as  a  rule,  less  interference  with 
urination  than  unilateral  hypertrophies  or  irregular  outgrowths.  One 
of  the  commonest  locations  of  the  affection  is  in  that  portion  of  the 
gland  lying  between  the  ejaculatory  ducts  and  base  of  the  bladder, 
which  when  enlarged  creates  the  so-called  third  lobe,  which  not  infre- 
quently projects  into  the  cavity  of  the  bladder,  elevates  the  urethral 
orifice,  and  sometimes  acts  as  a  ball  valve,  preventing  the  expulsion 
of  urine,  but  in  no  way  interfering  with  the  passage  of  a  catheter  into 
the  bladder. 

When  the  character  of  the  enlargement  is  such  as  to  cause  obstruc- 
tion to  the  outward  flow  of  urine,  there  occurs  a  compensatory  hyper- 
trophy of  the  muscular  walls  of  the  bladder.  The  thickened  muscular 
fibres  are  later  separated  by  distension  of  the  viseus,  and  a  prolapse  of 
the  mucous  membrane  occurs  between  the  separated  fasciculi,  giving 
rise  to  a  condition  described  as  a  trabeculated  bladder.  If  the  urethral 
obstruction  is  progressive,  the  urine  is  expelled  with  more  and  more 
difficulty,  a  condition  of  atony  gradually  ensues,  and  a  large  amount 
of  urine  is  habitually  retained  in  the  bladder  which  cannot  be  expelled 
by  voluntary  effort.  The  bladder  then  distends,  often  to  an  enor- 
mous size,  the  ureters  dilate,  and  a  condition  of  single  or  double 
hydronephrosis  may  result. 

In  practically  all  cases  of  obstructive  prostatic  hypertrophy,  infec- 
tion is  at  some  time  added  by  the  passage  of  an  instrument  for  pur- 
poses of  diagnosis  or  treatment.  If  this  occurs  at  an  early  period, 
before  the  obstruction  is  well  marked,  the  resulting  inflammatory 
process  may  be  limited  to  the  deep  urethra  or  bladder.  If  the  obstruc- 
tion is  considerable  and  there  is  much  residual  urine,  the  infection 
generally  spreads  rapidly  to  the  kidneys,  giving  rise  to  a  septic  pyelone- 
phritis which  may  prove  fatal  in  a  few  days  or  weeks. 

Symptoms. — These  occur  very  gradually,  and  rarely  attract  the 
attention  of  the  patient  until  they  have  existed  for  some  time.  There 
is  a  slight  frequency  in  urination,  especially  at  night.  With  this  there 
is  often  noticed  a  slight  diminution  in  the  force  of  the  stream  and  some 
delay  in  starting  the  flow. 


712     DISEASES  OF  TESTICLE,  SEMINAL  VESICLE,  PROSTATE 

The  symptoms  gradually  increase  in  severity.  The  calls  to  urinate 
are  more  frequent  and  urgent,  there  may  be  some  pain  at  the  close 
of  the  act,  and  there  is  a  feeling  of  weight  in  the  lower  abdomen  and 
perineum.  Considerable  variation  exists  in  the  severity  of  the  symp- 
toms, due  to  the  presence  or  absence  of  congestion  of  the  prostate, 
which  temporarily  increases  the  obstruction  and  irritability.  Attacks 
of  temporary  retention  are  of  frequent  occurrence  and  may  cause  great 
suffering.  While  the  bladder  remains  free  from  infection  the  urine  will 
be  clear,  and  the  patient  may  continue  in  excellent  health,  although 
his  rest  may  be  broken  by  frequent  calls  to  urinate,  and  he  may  surfer 
considerable  pain  at  each  act  of  micturition.  If,  however,  an  unclean 
instrument  is  for  any  reason  passed  into  the  bladder,  the  entire  clinical 
picture  may  suddenly  change.  Urination  becomes  much  more  fre- 
quent, extreme  urgency  and  vesical  tenesmus  are  added,  fever  appears, 
and  the  patient  is  prostrated.  The  urine  becomes  cloudy,  alkaline 
in  reaction,  contains  pus  and  often  albumin  and  casts.  Chills  and 
sweats  may  occur;  or  the  patient  may  gradually  sink  into  a  condition 
of  uremia  and  general  septic  intoxication,  ending  fatally  in  from  one  to 
two  weeks  from  the  date  of  infection.  If  the  infection  is  limited  to  the 
bladder  or  prostate,  the  symptoms  of  uremia  and  general  sepsis  may 
be  absent,  and  those  of  acute  prostatitis  or  cystitis  may  occur. 

In  many  of  these  cases  which  are  not  carefully  observed,  the 
diagnosis  of  malaria  or  typhoid  fever  is  honestly  made  by  those  in 
attendance. 

Diagnosis. — This  is  established  by  examination  of  the  gland  by  rectal 
palpation,  by  measuring  the  length  of  the  urethra,  and  by  ascertaining 
the  presence  of  residual  urine  in  the  bladder. 

In  the  majority  of  cases  of  enlargement  of  the  prostate,  the  examin- 
ing finger  will  easily  detect  it.  The  patient  should  be  examined  stand- 
ing with  his  trunk  flexed  at  a  right  angle  with  his  thighs,  the  hands  rest- 
ing upon  the  seat  of  a  chair  or  bench.  Under  normal  conditions 
the  forefinger  introduced  into  the  rectum  easily  reaches  a  point  well 
above  the  posterior  border  of  the  prostate.  It  should  be  remembered 
that  an  enlargement  of  the  so-called  third  lobe  projecting  into  the 
bladder,  capable  of  producing  complete  obstruction,  may  not  be  felt 
by  rectal  palpation. 

The  urethral  length  can  be  measured  by  introducing  a  soft-rubber 
catheter  and  noting  the  distance  from  the  meatus  at  which  the  urine 
begins  to  flow.  The  length  of  the  normal  urethra  is  about  seven  inches. 
In  hypertrophy  of  the  prostate  it  is  generally  increased.  In  some  cases 
the  distortion  of  the  gland  may  be  such  as  to  cause  the  prostatic  por- 
tion of  the  urethra  to  remain  open,  which  would  lead  to  error  in  estimat- 
ing the  urethral  length.  The  term  residual  urine  refers  to  that  portion 
left  in  the  bladder  after  ordinary  voluntary  micturition.  The  amount 
is  easily  ascertained  by  the  passage  of  a  catheter  immediately  after 
urination  and  emptying  the  bladder  by  pressure  above  the  pubis. 
In  general  it  may  be  stated  that  the  amount  of  residual  urine  habitually 


DISEASES  OF  THE  PROSTATE  GLAND  713 

left  in  the  bladder  is  a  reliable  index  of  the  functional  disturbance 
caused  by  the  prostatic  enlargement. 

The  presence  of  any  one  of  the  three  signs  just  mentioned,  asso- 
ciated with  a  non-inflammatory  irritability  of  the  bladder  in  a  man 
over  fifty,  would  render  the  diagnosis  of  enlarged  prostate  probable; 
the  occurrence  of  all  three  would  render  it  certain.  When  the  urethra 
easily  permits  the  passage  of  an  instrument  cytoscopy  will  be  of  value, 
especially  in  the  diagnosis  of  intravesical  growths. 

Treatment. — Enlarged  prostates  which  give  rise  only  to  slight 
vesical  irritability  without  serious  obstruction  and  without  residual 
urine  require  no  treatment.  It  is  wiser  also  to  avoid  the  introduction 
of  instruments  in  aged  subjects  with  moderate  symptoms  who  presum- 
ably have  a  certain  amount  of  residual  urine,  on  account  of  the  great 
danger  of  infection  and  its  disastrous  consequences  in  those  of  low  vital 
resistance.  In  younger  and  more  vigorous  subjects,  presenting  symp- 
toms of  prostatic  hypertrophy,  an  examination  should  be  made  to 
determine  the  presence,  and,  if  present,  the  amount  of  residual  urine. 
Such  examinations,  however,  should  never  be  undertaken  without 
explaining  the  dangers  to  the  patient  and  without  the  employment 
of  the  strictest  aseptic  precautions,  for  it  must  be  remembered  that  the 
first  introduction  of  a  catheter  into  the  bladder  of  a  subject  with 
chronic  obstructive  disease  of  the  prostate,  and  in  the  presence  of 
any  considerable  amount  of  residual  urine,  is  an  operation  the  mortality 
of  which  is  far  greater  than  that  following  removal  of  the  appendix. 

The  patient  should  be  placed  in  bed,  the  meatus  and  glans  penis 
disinfected,  and  the  anterior  urethra  irrigated  with  a  solution  of  mer- 
curic chloride  (1  to  10,000).  The  catheter  should  be  freshly  boiled, 
lubricated  with  sterile  white  vaseline  or  lubochondrine,  and  gently 
introduced  by  the  surgeon  after  thorough  preparation  of  his  hands.1 
Just  before  the  introduction  of  the  catheter  the  patient  should  be 
instructed  to  empty  the  bladder  as  completely  as  possible.  If  more  than 
an  ounce  of  residual  urine  is  found,  the  case  is  one  requiring  treatment. 

Two  methods  of  treatment  are  open  to  the  patient,  the  palliative 
and  the  radical.  The  former  aims  to  relieve  the  painful  symptoms  by 
regular  catheterism;  the  latter,  to  cure  the  disease  by  removing  the 
obstruction. 

Catheterism  is  indicated  in  certain  cases  in  which  the  amount  of 
residual  urine  is  comparatively  small,  in  which  the  instrument  can  be 
used  without  undue  force,  in  which  it  excites  no  reaction,  and  in  old 
and  enfeebled  subjects  whose  condition  is  such  as  to  contra-indicate 
operative  procedures. 

The  patient  should  devote  at  least  a  week  to  the  process  of  begin- 
ning his  catheter-life.  He  should  remain  in  bed  for  two  or  three  days, 
to  avoid  any  possible  exposure  and  to  insure  absolute  rest.  The 
catheter  invariably  should  be  introduced  in  the  manner  just  indicated 

1  It  has  been  our  custom  at  the  Roosevelt  Hospital  for  a  number  of  years  to  insist 
upon  freshly  sterilized  rubber  gloves  being  used  in  every  catheterization. 


714     DISEASES  OF  TESTICLE,  SEMINAL  VESICLE,  PROSTATE 

and  with  the  precautions  stated,  the  patient  being  particularly  in- 
structed in  regard  to  the  care  of  his  hands  and  the  instrument.  He 
should  keep  a  number  of  catheters  on  hand,  and  should  discard  them 
as  soon  as  they  become  brittle  or  in  any  way  defective.  If  chronic 
cystitis  exists,  a  daily  irrigation  with  boric  acid  solution  is  to  be 
advised. 

The  soft-rubber  velvet-eyed  or  coude  catheter  is  the  safest  instru- 
ment to  use,  but  the  gum-elastic  is  often  preferred  by  patients  on 
account  of  its  stiffness.  The  one  with  the  coude  point  is  generally 
satisfactory.  As  the  object  of  the  catheterism  in  the  beginning  is  to 
prevent  increase  in  the  residual  urine  and  consequent  atony  of  the 
bladder,  the  employment  of  the  instrument  once  or  twice  a  day  gen- 
erally will  be  sufficient.  When  voluntary  urination  becomes  greatly 
embarrassed  and  painful,  it  is  better  to  depend  upon  the  catheter 
rather  than  to  permit  the  patient  to  strain  and  congest  the  parts  by 
voluntary  efforts.  The  rule,  however,  in  these  cases  should  be  to 
empty  the  bladder  completely  at  each  catheterization,  and  to  employ 
it  as  infrequently  as  possible.  As  a  rule,  great  comfort  will  be  expe- 
rienced by  the  patient  as  soon  as  he  becomes  well  established  in  his 
catheter-life.  Attacks  of  bladder  infection  are,  however,  almost  sure 
to  occur  from  time  to  time  as  a  result  of  some  error  in  technic.  After 
the  back-pressure  on  the  ureters  and.  kidneys  has  been  removed  by  the 
avoidance  of  an  accumulation  of  residual  urine,  such  attacks  are  less 
dangerous  for  the  reason  that  the  infection  generally  remains  limited 
to  the  bladder  and  posterior  urethra,  a  situation  in  which  it  is  readily 
amenable  to  treatment. 

If  difficulty  is  experienced  in  the  passage  of  the  catheter,  or  in 
voluntary  micturition,  the  occasional  use  of  a  full-sized  sound  will 
afford  temporary  relief.  Permanent  suprapubic  or  perineal  bladder 
drainage  is  occasionally  resorted  to  for  relief  of  pain  and  retention 
in  patients  who  are  unable  to  withstand  the  shock  of  the  more  radical 
procedures. 

While  catheterism  and  vesical  drainage  are  often  indicated  in  the 
old  and  feeble  subjects  of  prostatic  hypertrophy,  most  surgeons  now 
recognize  the  fact  that  the  safest  procedure  in  the  majority  of 
instances  is  the  operation  of  prostatectomy  or  surgical  removal  of 
the  obstructing  gland.  The  Bottini  operation,  or  deep  cauterization 
of  the  thickened  neck  of  the  bladder,  formerly  practised  with  con- 
siderable temporary  relief  has  now  been  practically  abandoned. 

The  advantages  of  prostatectomy  are  the  fact  that  it  is  the  only 
procedure  which  actually  removes  the  cause  of  the  obstruction  and 
gives  permanent  results;  that,  with  our  present  improved  technic, 
the  mortality  has  been  reduced  to  a  point  even  below  that  of  the 
Bottini  operation ;  and  that  when  relief  is  once  obtained,  a  recurrence 
of  the  symptoms  is  not  likely  to  occur.  It  must  not  be  forgotten,  how- 
ever, that  incontinence  of  urine  may  follow  the  operation,  and  that  a 
perineal  or  suprapubic  urinary  fistula  has  occasionally  remained. 


TUMORS  OF  THE  PROSTATE  GLAND  715 


TUMORS    OF    THE    PROSTATE    GLAND. 

Carcinoma.- Cancer  of  the  prostate,  formerly  supposed  to  be  an 
extremely  rare  disease,  is  now  known  to  he  of  fairly  frequent  occurrence. 
The  investigations  of  Albarran  and  Hall  and  of  Young  have  demon- 
strated that  from  10  to  14  per  cent,  of  all  non-inflammatory  senile 
enlargements  of  the  prostate  are  carcinomatous  in  character. 

While  cancer  of  the  prostate  may  and  frequently  does  begin 
as  a  malignant  neoplasm,  in  a  large  number  of  instances  it  is 
engrafted  upon  a  senile  hypertrophy,  particularly  of  the  adenomatous 
type.  This  is  clearly  proved  by  the  large  number  of  reported  cases 
where  individuals,  suffering  for  years  from  the  characteristic  symptoms 
of  senile  hypertrophy,  aFe  operated  upon,  and  the  tissue  removed 
is  later  found  to  present  the  histologic  evidences  of  beginning  malignant 
change.  These  cases  cannot  be  recognized  clinically,  as  the  malignant 
disease  has  not  advanced  to  such  an  extent  as  to  give  rise  to  character- 
istic symptoms  or  signs. 

The  cases  which  are  easily  recognized  clinically  present  an  en- 
tirely different  picture.  In  these  the  process  extends  so  rapidly  to 
the  very  abundant  lymphatic  system  of  the  pelvis  that  Guyon  has 
suggested  the  term  prostatopelvic  carcinosis,  and  has  strongly  advised 
against  any  attempt  at  radical  operation. 

Young  believes  that  there  is  a  stage  of  the  disease  between  these 
two  extreme  types  which  can  be  recognized  clinically,  and  in  which 
the  disease  is  still  limited  to  the  gland  or  its  immediate  vicinity.  In 
these  cases  he  believes  that  radical  removal  holds  out  some  hope  for 
permanent  cure. 

Regarding  the  clinical  course  of  the  disease,  it  may  be  said  to  be 
comparatively  slow,  as  many  cases  are  on  record  where  it  has  existed 
For  four  or  five  years,  and  as  this  is  after  its  clinical  recognition,  the 
actual  duration  of  these  cases  is  undoubtedly  much  longer.  » 

Symptoms. — The  symptoms  of  cancer  of  the  prostate,  in  its  advanced 
stages,  are  characteristic.  The  occurrence  of  pain,  frequency,  hema- 
turia, partial  obstruction,  and  the  presence  of  a  hard,  nodular  growth, 
involving  the  prostate,  base  of  the  bladder,  and  rectum,  will  enable 
the  surgeon  to  diagnosticate  the  true  condition. 

In  the  earlier  stages,  when  surgical  intervention  alone  holds  out 
any  hope  for  permanent  relief,  local  symptoms  may  be  absent,  or 
only  those  of  senile  hypertrophy  may  be  present.  To  the  palpating 
finger  the  gland  feels  abnormally  hard,  and  there  may  be  an  induration 
extending  upward  along  the  ejaculatory  ducts,  or,  as  Young  has 
described  it,  an  indurated  plate  between  the  seminal  vesicles.  In 
slightly  more  advanced  cases  pain  over  the  distribution  of  the  sciatic 
nerve  may  be  present;  also,  slight  hematuria,  especially  after  instru- 
mental exploration,  and  a  nodular  feeling  of  the  organ  to  the  palpating 
finger. 


716     DISEASES  OF  TESTICLE,  SEMINAL  VESICLE,  PROSTATE 

Bone  metastasis  is  quite  common.  Visceral  metastasis  and  cachexia 
occur  late  in  the  disease. 

Prognosis. — Sufficient  data  are  not  available  to  enable  one  to  formu- 
late any  definite  conclusion  regarding  the  value  of  the  modern  radical 
operation.  There  seems  to  be  no  valid  reason,  however,  for  doubting 
that  here,  as  elsewhere  in  the  body,  early  and  thorough  extirpation  of 
the  disease  may  not  effect  a  cure. 

Treatment. — When  there  is  reason  to  believe  that  carcinoma  has  been 
engrafted  upon  a  senile  hypertrophy  of  the  prostate,  Young  advises 
prostatectomy  and  the  immediate  examination  by  a  frozen  section  of 
the  tissue  removed.  If  the  microscope  demonstrates  the  disease,  the 
radical  operation  should  be  performed.  In  other  cases,  where  the 
characteristic  signs  of  carcinoma  are  present,  radical  removal  should 
be  undertaken,  unless  the  growth  has  advanced  so  far  as  to  render 
complete  removal  impossible. 

In  hopelessly  advanced  cases  perineal  or  suprapubic  drainage  will 
often  give  a  large  measure  of  relief. 

Sarcoma. — Sarcoma  of  the  prostate  is  much  rarer  than  carcinoma, 
the  proportion  being  about  1  to  4.  While  in  some  cases  the  rapid 
growth  of  a  soft  tumor  would  suggest  the  probability  of  sarcoma,  in 
most  instances  the  disease  cannot  be  distinguished  clinically  from 
carcinoma.  The  prognosis  and  treatment  of  this  disease  should  be  the 
same  as  in  carcinoma. 

OPERATIONS    ON   THE   GENITAL   ORGANS. 

Castration. — An  incision  is  made  over  the  loose  inguinal  region  or 
upper  part  of  the  scrotum  in  the  line  of  the  spermatic  cord,  including 
the  skin  and  dartos.  The  cord  and  testicle  are  separated  from  their 
bed  of  areolar  tissue  and  drawn  outward  through  the  cutaneous  open- 
ing. The  various  tunics  are  opened  over  the  upper  part  of  the  cord 
and  the  vessels  and  vas  deferens  ligated  separately.  The  cord  is  then 
divided  and  the  testicle  removed,  the  scrotum  drained  through  an 
opening  made  in  the  bottom  of  the  sac,  and  the  wound  united  with  silk. 
If  the  castration  is  for  malignant  or  tuberculous  disease,  the  inguinal 
canal  should  be  opened  as  in  the  operation  for  hernia,  the  cord  followed 
upward  to  the  internal  ring,  and  drawn  downward  as  far  as  possible 
and  treated  in  the  same  manner.  Inguinal  or  retroperitoneal  lymph- 
node  metastases,  in  cases  of  malignant  disease,  should  be  thoroughly 
removed. 

Epididymectomy. — The  testicle  is  exposed  as  for  castration,  the  cavity 
of  the  tunica  vaginalis  opened,  the  epididymis  carefully  dissected  from 
the  testicle  and  removed  with  as  much  of  the  vas  deferens  as  is  diseased. 
The  wound  is  then  closed  with  a  small  rubber  tissue  drain  extending 
to  the  cavity  of  the  tunica. 

Epididymovasostomy. — This  operation  is  recommended  for  the 
cure  of  sterility  due  to  inflammatory  occlusion  of  the  vas  deferens  in 


OPERATIONS  ON  THE  GENITAL  ORGANS  717 

the  globus  minor.  It  can  be  performed  with  local  anesthesia.  An  inci- 
sion is  made  through  the  posterior  wall  of  the  scrotum  and  the  tunica 
vaginalis  opened.  The  vas  is  next  isolated,  divided  by  an  oblique 
incfsion,  and  the  lumen  still  further  slit  up  with  fine-pointed  scissors. 
The  tissue  at  the  head  of  the  epididymis  is  next  grasped  by  a  small 
mouse-tooth  forceps,  and  a  small  section  removed  by  curved  scissors. 
If  a  patent  tube  is  opened,  a  small  amount  of  yellowish  fluid  will  now 
appear,  which  immediately  should  be  examined  by  the  microscope  to 
demonstrate  the  presence  of  living  spermatozoa.  The  open  proximal 
portion  of  the  vas  is  then  placed  over  the  opening  in  the  globus  major 
and  held  by  a  few  fine  chromic  catgut  sutures.  In  this  operation 
great  care  should  be  used  not  to  injure  or  wound  the  veins  of  the  cord, 
on  account  of  the  danger  of  thrombosis,  which  seriously  interferes  with 
prompt  recovery.  As  a  rule,  the  wound  is  closed  without  drainage,  a 
suitable  dressing  applied,  which  is  held  in  place  by  a  suspensory,  and 
the  patient  treated  as  an  ambulant  case. 

Exposure  of  the  Prostate  and  Seminal  Vesicle.— This  operation  is 
accomplished  best  by  the  Zuckerkandl  curved  incision,  extending  across 
the  perineal  space  from  one  tuberosity  to  the  other,  the  summit  of 
the  curve  being  well  above  the  anal  orifice.  The  incision  is  gradually 
deepened  to  the  end  of  the  bulb,  and  the  central  tendon  divided  with 
scissors.  Just  behind  the  central  tendon  another  point  of  attachment 
will  be  found  between  the  rectum  and  the  membranous  urethra,  the 
redo-urethral  muscle.  This  should  be  divided  close  to  the  urethra,  which 
allows  the  rectum  to  fall  backward  into  the  hollow  of  the  sacrum,  and 
greatly  increases  the  operative  space.  The  prostate  is  now  easily  ex- 
posed by  blunt  dissection,  and,  by  carrying  the  dissection  well  above  the 
upper  border  of  the  prostate,  the  seminal  vesicles  can  be  brought  into 
view.  In  performing  this  operation  the  patient  should  be  in  the  lithot- 
omy position  with  the  thighs  flexed  as  acutely  as  possible.  A  steel 
sound  should  be  placed  in  the  bladder  as  a  guide  and  the  rectum  kept 
well  out  of  the  way  by  a  retractor.  Through  this  incision  abscesses  of 
the  prostate  or  vesicle  may  be  opened  and  drained. 

Removal  of  the  Entire  Genital  Tract. — Removal  of  the  entire  genital 
tract  is  indicated  when  there  is  tuberculous  disease  of  the  testicle,  vas, 
and  seminal  vesicle  on  one  side  only,  without  involvement  of  the  pros- 
tate. The  patient  is  placed  in  the  lithotomy  position  and  the  seminal 
vesicle  exposed  by  the  Zuckerkandl  incision,  after  which  it  is  carefully 
separated  from  the  prostate  by  blunt  dissection,  care  being  taken  to 
avoid  wounding  the  urethra  and  rectum.  After  the  vesicle  and  the 
adjacent  portion  of  the  vas  are  dissected  free,  the  position  of  the 
patient  is  changed  and  the  regular  operation  for  castration  performed, 
the  cord  being  followed  upward  to  the  brim  of  the  pelvis  by  free  dis- 
section of  the  structures  in  the  neighborhood  of  the  internal  ring.  The 
testical  and  vesicle  are  then  grasped  by  the  operator  and  a  sawing 
motion  made,  which  will  quickly  separate  the  deeper  portions  of  the 
vas  from  the  surrounding  tissue,  after  which  the  cord  is  divided  at 


718     DISEASES  OF  TESTICLE,  SEMINAL  VESICLE,  PROSTATE 

the  internal  ring  and  both  ends  removed.  The  wounds  are  then  united 
as  described  above. 

Prostatectomy. — The  suprapubic  route  should  be  chosen  for  large 
intravesical  outgrowths;  the  perineal,  for  enlargements  of  the  lateral 
lobes. 

Suprapubic  Prostatectomy. — Suprapubic  prostatectomy,  by  Fuller's 
method,  is  performed  as  follows:     The  bladder  is  opened  above  the 


I 


Fig.  328. — Young's  prostatic  tractor  closed  and  ready  for  introduction. 

pubis  as  described  on  page  661.  The  prostatic  enlargement  is  appre- 
ciated by  the  examining  finger  and  the  bladder  wall  incised,  preferably 
by  heavy  scissors,  from  the  lower  margin  of  the  internal  urethral  orifice, 
backward  in  the  median  line,  over  the  tumor-mass.  The  forefinger  of 
the  right  hand  is  next  introduced  through  this  incision,  while  the  closed 
fist  of  the  left  hand  makes  firm  upward  pressure  against  the  perineum. 
This  forces  the  tumor  high  into  the  pelvis,  where  it  generally  can  be 
enucleated  by  the  finger  of  the  right  hand.  All  obstructing  tissue  should 
be  removed  and  the  urethra  subsequently  explored  to  insure  its  free- 


Fig.  329. — Same  open. 

dom  from  projecting  masses.  A  large  perineal  drainage  tube  is  next 
introduced  and  the  bladder  irrigated  for  several  minutes  with  hot  salt 
solution  to  control  the  oozing.  If  the  bleeding  is  not  such  as  to  neces- 
sitate packing  the  bladder,  the  suprapubic  wound  is  partly  united  with 
two  rows  of  sutures,  and  a  single  medium-sized  rubber  tube  intro- 
duced and  allowed  to  remain  for  three  or  four  days,  after  which  it  is 
removed  and  the  wound  closed  by  tying  a  previously  introduced  pro- 


OPERATIONS  OS   THE  GESITAL  ORGANS 


719 


visional  suture  of  silkworm  gut,  which  should  include  skin,  muscle, 
and  bladder  wall.  The  perineal  tube  should  be  allowed  to  remain  in 
place  for  a  week  or  ten  days.  J.  Bentley  Squire  has  modified  this  pro- 
cedure somewhat.  After  the  bladder  is  opened  he  introduces  the 
index  finger  into  the  prostatic  urethra  until  the  anterior  limit  of  the 


Fig.    330. — Young's    technic:    prostate   brought    down   and    lateral   incisions   made    in 

capsule.     (After  Young.) 


growth  is  reached.  The  urethral  mucous  membrane  is  then  torn,  and 
the  prostatic  enucleated  from  the  triangular  ligament  backward 
toward  the  bladder.  By  this  procedure  he  believes  there  is  less  injury 
to  the  vesical  sphincter. 

Perineal   Prostatectomy. — The    simplest   method    of    perineal    pros- 
tatectomy is  Alexander's  operation.     The  patient  is  placed  in  the 


720     DISEASES  OF  TESTICLE,  SEMINAL   VESICLE,  PROSTATE 

lithotomy  position.  The  membranous  urethra  is  opened  through  a 
generous  perineal  incision  and  the  finger  introduced  into  the  prostatic 
portion  of  the  canal.  The  mucous  membrane  on  the  floor  of  the 
prostatic  urethra  and  the  capsule  of  the  prostate  are  then  torn  by  the 
finger-nail  and  each  lateral  lobe  enucleated  by  the  forefinger,  while  the 
mass  is  forced  well  downward  by  the  left  hand  by  suprapubic  press- 
ure. After  the  prostate  is  removed  the  bladder  is  irrigated  with  hot 
sterile  salt  solutions  and  perineal  drainage  established. 


Fig.  331. — Young's  technic:    separation  of  capsule  with   blunt  dissector. 
(After  Young.) 


Parker  Syms  draws  the  prostate  well  downward  in  the  perineal 
wound  by  traction  on  a  rubber  ball  introduced  into  the  bladder  through 
the  urethral  wound,  and  subsequently  inflated.  This  gives  excellent 
control  of  the  gland. 

Hugh  Young  employs  a  metal  retractor  (Fig.  328)  which  is  shaped 
like  a  steel  sound.  This,  when  introduced  into  the  bladder,  is  opened 
(Fig.  329),  and  with  it  the  prostate  often  can  be  drawn  downward 
to  the  margin  of  the  cutaneous  incision.  In  Young's  operation  the 
prostate  is  exposed  as  described  above,  and  the  retractor  introduced 
through  an  opening  made  in  the  membranous  urethra.     By  drawing 


OPERATIONS  ON   THE  GENITAL  ORGANS 


721 


the  prostate  well  downward  and  elevating  the  handle  of  the  retractor 
the  entire  posterior  surface  of  the  gland  can  be  brought  into  view.  He 
next  makes  two  slightly  diverging  longitudinal  incisions  through  the 
capsule,  and  by  means  of  a  blunt  dissector  separates  the  lobe  from  the 
capsule  after  which  removal  is  effected  by  the  finger  or  a  pair  of  flat 
fenestrated  lobe  forceps  (Figs.  330,  331,  and  332). 

Young  states  that  he  is  able  by  this  plan  to  remove  practically  all 
enlarged  prostates.  He  recently  reported  over  100  consecutive  cases 
without  a  death. 


Fig.  332. — Young's  technic 


withdrawing  lateral  lobes  after  being  enucleated.     (After 
Young.) 


Young's  Radical  Operation  for  Carcinoma  of  the  Prostate. — The  pros- 
tate is  exposed  as  described  in  the  previous  section,  the  membranous 
urethra  cut  across,  and  the  retractor  introduced  into  the  bladder. 
The  handle  is  next  sharply  depressed  and  the  puboprostatic  ligaments 
divided.  This  enables  the  operator  to  drawT  the  prostate  well  down 
and  often  outside  of  the  cutaneous  incision.  The  bladder  is  then 
opened  from  in  front,  just  behind  the  upper  margin  of  the  gland,  and 
the  trigone  exposed.  The  incision  is  next  carried  downward  on  either 
side,  and  the  floor  divided  just  distal  to  the  ureteral  orifices.  The  sem- 
46 


722     DISEASES  OF  TESTICLE,  SEMINAL  VESICLE,   PROSTATE 

inal  vesicles  are  separated  from  their  attachments  and  the  vasa  defer- 
entia  divided  as  high  up  as  possible.  The  entire  mass,  consisting  of 
the  prostate,  vesicles,  and  vasa  deferentia,  is  removed,  and  the  large 
bladder  wound  reduced  in  size  and  united  to  the  distal  portion  of  the 
urethra  by  sutures.  The  levator  muscle  is  drawn  together  by  one  or 
two  heavy  catgut  sutures,  a  soft-rubber  catheter  introduced  through 
the  urethra  to  the  bladder,  the  cutaneous  wound  partly  united,  and 
a  small  gauze  drain  inserted. 


CHAPTER  XXVI. 
INJURIES  AND  DISEASES  OF  THE  RECTUM  AND  ANUS. 

CONGENITAL    MALFORMATIONS    OF   THE   RECTUM    AND    ANUS. 

The  rectum  is  formed  by  the  union  of  the  caudal  extremity  of  the 
primitive  hind  gut  and  the  proctodeum  or  cutaneous  anal  depression. 
Arrest  of  development  may  result  in  stenosis  of  the  canal,  congenital 
stricture  of  the  rectum;  in  the  presence  of  a  membranous  septum, 
imperforate  anus;  or  in  complete  absence  of  the  anal  depression,  with 
or  without  the  presence  of  a  blind  rectal  pouch  in  the  hollow  of  the 
sacrum.  This  pouch  when  present  may  or  may  not  retain  its  original 
connection  with  the  genito-urinary  tract.  In  the  former  case  the 
alimentary  canal  may  open  into  the  bladder,  urethra,  or  vagina;  in 
the  latter,  complete  intestinal  atresia  is  present. 

Treatment. — Congenital  strictures  (generally  located  about  one  inch 
above  the  anus)  are  to  be  treated  by  gradual  dilatation.  Membran- 
ous septa  may  be  perforated  and  subsequently  dilated.  Blind  rectal 
pouches  should  be  sought  for  by  perineal  incision,  and,  when  found, 
brought  down  and  sutured  to  the  skin  of  the  perineum  when  this  is 
possible.  When  the  rectum  is  too  short  the  opening  may  be  estab- 
lished higher,  as  in  the  Kraske  resection,  or  by  inguinal  colostomy. 
Communications  with  the  bladder  usually  close  spontaneously  after 
a  free  exit  is  given  for  the  intestinal  contents. 

INJURIES    AND   DISEASES    OF    THE   RECTUM   AND   ANUS. 

Wounds  of  the  Rectum. — Injuries  to  the  rectum  are  rare  on  account 
of  its  protected  position.  Lacerations  about  the  anus  and  extending 
into  the  bowel  may  be  caused  by  falls  upon  pointed  objects,  by  automo- 
bile or  railway  accidents,  and  by  other  traumata.  The  writer  has 
twice  observed  severe  lacerations  caused  by  the  horns  of  an  infuriated 
bull.  Such  injuries  may  involve  the  bladder  or  urethra,  or  may  extend 
upward  and  enter  the  peritoneal  cavity.  The  rectum  not  infrequently 
is  injured  during  surgical  operations,  as  in  the  removal  of  the  prostate 
or  in  perineal  cystotomy. 

In  the  treatment  of  wounds  of  the  rectum  the  same  surgical  prin- 
ciples should  apply  as  in  other  localities.  If  there  is  reason  to  believe 
that  the  peritoneal  cavity  has  been  entered,  laparotomy  should  be 
performed  and  the  rectal  injury  repaired  from  above.  If  the  wound 
is  confined  to  the  lower  portion  of  the  gut,  its  site  should  be  exposed  by 


724  DISEASES  OF   THE  RECTUM  AND  ANUS 

a  generous  incision  with  partial  resection  of  sacrum,  if  necessary,  and 
the  wound  repaired  by  layer  suture.  In  the  extraperitoneal  portion  of 
the  rectum  repair  is  slower  and  leakage  is  apt  to  occur.  Adequate 
drainage  should,  therefore,  be  employed  in  these  cases. 

When  the  wound  involves  the  sphincter  muscle  great  care  should 
be  exercised  to  bring  the  divided  muscular  fibres  together.  If  the 
circular  fibres  are  completely  divided,  the  ends  retract,  and  must  be 
sought  for  and  identified  by  careful  dissection.  When  foimd  they 
should  be  brought  together  by  one  or  more  buried  mattress  sutures  of 
chromic  gut,  after  which  the  skin  and  mucous  membrane  should  be 
united  by  silk.  When  considerable  laceration  or  loss  of  tissue  has 
occurred,  or  where  the  parts  are  hopelessly  infected,  the  chief  effort 
should  be  to  combat  the  infection,  the  repair  of  the  muscle  to  be  under- 
taken at  a  later  period. 

Rupture  of  the  rectum  without  external  injury  has  been  reported  in 
a  few  instances.  Burkhardt  collected  14  cases,  13  of  which  proved 
fatal.  Severe  straining  at  stool  is  given  as  the  most  frequent  cause. 
Where  the  rupture  occurs  into  the  peritoneal  cavity  the  indications 
are  for  laparotomy  and  suture  of  the  bowel  wound  when  this  is  possible. 
If  local  repair  is  impossible,  colostomy  should  be  performed. 

Proctitis. — Proctitis  is  an  inflammation  of  the  rectal  mucous  mem- 
brane, caused  by  extension  of  an  infection  from  above  (colitis)  or  one 
introduced  from  without  (gonorrhea  or  venereal  ulcer);  from  the 
presence  of  a  wound  or  foreign  body,  a  new  growth,  or  ulceration. 

Symptoms. — The  symptoms  of  proctitis  are  pain,  rectal  tenesmus,  and 
the  frequent  passage  of  stools  containing  blood  and  mucus. 

Treatment. — The  treatment  should  consist  in  removal  of  the  cause, 
rest,  rectal  irrigation,  and  the  use  of  suppositories  of  opium  to  control 
the  pain  and  tenesmus.  Hot  sitz  baths  and  fomentations  to  the  anal 
region  often  afford  marked  relief.  In  the  chronic  cases  injections  of  a 
solution  of  glycerite  of  tannin  (1  to  20)  will  be  of  value  in  lessening  the 
mucous  secretion. 

Periproctitis. — Periproctitis,  or  ischiorectal  abscess,  is  a  septic  inflam- 
mation of  the  cellular  tissue  in  the  ischiorectal  fossa,  caused  by  infec- 
tion from  the  bowel  by  perforations  of  the  mucous  membrane  from 
fish-bones  or  other  foreign  bodies,  from  ulcerations,  and  from  follicular 
abscesses;  from  infections  from  the  genito-urinary  passages,  as 
extravasations  of  urine,  periurethral  abscess  or  prostatitis;  or  from 
infections  from  without,  the  result  of  wounds  or  severe  contusions. 

Symptoms. — The  symptoms  of  ischiorectal  suppuration  are  pain, 
and  tenderness  in  the  neighborhood  of  the  anus,  with  fever  and  general 
malaise.  On  palpation  an  indurated  area  can  be  felt  on  one  side 
of  the  rectum,  and  the  extent  of  the  mass  may  generally  be  appre- 
ciated by  the  finger  introduced  within  the  bowel.  Redness,  swelling, 
edema  of  the  skin,  and  fluctuation  appear  later,  and  spontaneous 
rupture  may  occur.  Periprostatic  abscess,  and  occasionally  deep- 
seated  suppuration  from  infection  of  the  lymph  nodes  accompanying 


INJURIES  AND  DISEASES  OF  THE  RECTUM  AND  ANUS     725 

the  internal  iliac  veins,  may  rupture  through  the  pelvic  diaphragm 
and  give  rise  to  ischiorectal  suppuration.  In  these  eases  drainage  is 
imperfect  even  after  free  evacuation  of  the  ischiorectal  focus,  and 
symptoms  of  absorption  continue  until  the  pockets  above  the  levator 
ani  muscle  arc  thoroughly  drained. 

Treatment. — Early  incision  and  drainage  constitute  the  only  treat- 
ment of  this  condition.  As  the  areolar  tissue  of  the  ischiorectal  fossa  is 
loose  and  easily  broken  down,  extensive  burrowing  of  pus  takes  place, 
requiring  large  incisions  frequently  on  both  sides  of  the  rectum;  and 
in  chronic,  long-standing  cases  the  deepest  recesses  of  the  space  should 
be  freely  exposed  and  packed.  As  the  majority  of  these  cases  are 
caused  by  infection  from  the  bowel,  in  many  instances  a  fistula  results, 
requiring  subsequent  treatment. 

Fistula  in  Ano. — Fistula  in  ano  is  a  sinus  passing  from  the  rectum 
to  a  cutaneous  opening  in  the  neighborhood  of  the  anus.  The  older 
writers  were  accustomed  to  describe  three  forms:  a  blind  internal,  a 
blind  externa],  and  one  open  at  both  extremities  (Fig.  333).  It  is 
obvious  that  only  the  latter  form  can  properly  be  classed  as  a  fistula. 
Blind  internal  sinuses  generally  result  from  rupture  of  an  abscess 


Fig.  333. — Diagram  of  three  forms  of  anal  fistula.     (Roberts.)      A,  complete  fistula; 
B,  incomplete  internal  fistula;  C,  incomplete  external  fistula. 

into  the  lectum;  blind  external  sinuses  practically  never  persist  unless 
due  to  a  foreign  body,  bone  disease,  or  to  a  tuberculous,  syphilitic,  or 
actinomycotic  focus. 

In  the  majority  of  instances  a  fistula  is  the  result  of  an  ischio- 
rectal abscess  which  has  been  caused  by  a  break  in  the  mucous  mem- 
brane of  the  rectum.  After  the  abscess  is  evacuated,  mucus  and 
intestinal  matter  continue  to  leak  from  the  bowel  into  the  abscess 
cavity,  which  prevents  healing  and  results  in  the  formation  of  a  nar- 
row sinus  lined  with  granulation-tissue.  The  sinus  may  be  straight, 
easily  admitting  a  probe;  or  it  may  be  exceedingly  tortuous  and  have 
several  cutaneous  orifices  situated  at  a  distance  from  each  other. 
A  small  number  of  fistulas  are  tuberculous  in  origin. 

Diagnosis. — As  a  rule,  the  patients  complain  of  nothing  but  a  slight 
mucous  or  mucopurulent  secretion,  which  constantly  exudes  from  a 
minute  opening,  which  may  be  situated  in  the  scar  of  an  incision  or 
may  be  surrounded  by  a  bluish  elevated  papule.  In  some  cases  the 
entire  ischiorectal  region  is  indurated  and  presents  numerous  fistulous 
openings.  On  rectal  examination  the  finger  may  often  detect  an 
elevated  papule  which  is  the  seat  of  the  internal  opening.    The  passage 


726  DISEASES  OF   THE  RECTUM  AND  ANUS 

of  a  probe  from  the  external  to  the  internal  opening  establishes  the 
diagnosis.  This,  however,  is  often  impossible  without  general  anes- 
thesia on  account  of  the  tortuous  character  of  the  sinus  and  the  sensi- 
tiveness of  the  parts. 

Treatment. — When  multiple  openings  exist,  these  should  be  followed 
up  and  freely  opened  to  the  main  focus;  a  grooved  director  should  then 
be  passed  from  the  main  focus  to  the  internal  opening,  and  all  the 
tissues  divided  by  passing  the  blade  of  the  knife  along  the  groove  in 
the  director.  An  effort  should  always  be  made  to  divide  the  sphincter 
muscle  but  once,  and  then  transversely  to  the  direction  of  its  fibres. 
The  entire  sinus  should  be  thoroughly  curetted  and  touched  with  the 
actual  cautery,  or  it  may  be  completely  dissected  from  the  surrounding 
tissues  and  removed.  The  wound  should  then  be  tightly  packed  with 
sterile  or  iodoform  gauze,  and  an  external  pad  of  gauze  applied  and  held 
in  place  by  a  T-bandage.  The  bowels  should  be  confined  for  three  or 
four  days,  after  which  a  purge  and  enema  may  be  given.  After  each 
evacuation  of  the  bowels  the  parts  should  be  irrigated  and  the  wound 
firmly  packed  to  insure  healing  from  the  bottom.  Suture  of  the  wound 
after  dissecting  out  the  sinus  with  a  view  to  obtaining  primary  union 
is  successful  in  a  certain  number  of  instances.  If  this  plan  is  followed, 
the  bowels  should  be  confined  for  from  six  to  ten  days.  Considerable 
time  may  be  saved  by  this  procedure  even  if  that  portion  of  the  wound 
nearest  the  bowel  does  become  infected.  It  occasionally  happens 
that  the  opening  into  the  rectum  is  so  high  (three  inches  or  more)  that 
the  ordinary  method  of  treatment  cannot  be  carried  out.  In  these 
cases  it  is  better  to  expose  the  opening  into  the  rectum  by  a  large 
incision  and  close  it  by  layer  sutures,  or  to  perform  an  inguinal  colos- 
tomy, and  attempt  to  close  the  rectal  wound  from  within  through  a 
large  rectal  speculum. 

Stricture  of  the  Rectum. — Stenosis  of  the  rectum,  as  in  other  portions 
of  the  alimentary  canal,  may  be  caused  by  new  growths,  by  inflam- 
matory thickening  of  its  walls,  by  a  cicatricial  contraction  following  the 
healing  of  an  ulcer,  or  by  outside  pressure. 

Inflammatory  or  fibrous  stricture,  which  alone  will  be  considered  in 
this  section,  is  a  fairly  common  affection,  and  in  the  majority  of 
instances  is  the  sequel  of  simple  ulcer,  dysentery,  gummatous  ulcer- 
ation, trauma,  or  chancroidal  disease.  The  stricture  may  be  situated 
in  any  part  of  the  rectum,  but  is  generally  found  within  three  inches 
of  the  anus.  As  a  rule,  the  constricting  band  completely  encircles  the 
gut  and  is  limited  in  extent,  giving  rise  in  some  instances  to  a  condition 
similar  to  that  produced  by  a  cord  tied  around  the  bowel. 

Symptoms. — The  symptoms  of  stricture  of  the  rectum  are  pain,  a 
gradually  increasing  constipation  with  occasional  attacks  of  diarrhea 
accompanied  by  tenesmus  and  the  passage  of  mucus  and  blood, 
indefinite  digestive  symptoms,  and  in  later  stages  a  gradual  distension 
of  the  abdomen. 

Defecation  becomes  painful  and  slow,  great  straining  being  required. 


INJURIES  AND  DISEASES  OF  THE  RECTUM   AND  ANUS      727 


The  stools,  when  diarrhea  is  not  present,  are  small  in  size  and  often 
flattened  like  ribbons.    When  the  stricture  is  situated  low  down  within 
reach  of  the  examining  finger,  the  diagnosis  is  easy.    When  higher  up, 
the  proctoscope  reveals  the  pres- 
ence of    a    narrow    opening    sur- 
rounded by  an  indurated  ring  of 
cicatricial  tissue.1 

Treatment.  —  Fibrous  strictures 
of  the  rectum  are  best  treated 
by  gradual  dilatation,  solid  rubber 
or  gum-elastic  bougies  being  em- 
ployed. When  the  stricture  does 
not  yield  to  this  treatment  linear 
proctotomy  may  be  employed. 
This  consists  in  dilating  the  sphinc- 
ter, exposing  the  interior  of  the 
gut  by  a  wire  speculum,  or  retrac- 
ting the  walls  by  ordinary  flat  re- 
tractors, and  incising  the  band  in 

the  median  line.  Following  the  operation  the  rectum  should  be  fre- 
quently irrigated  with  warm  salt  solution,  and  full-sized  bougies  passed 
every  second  day  until  healing  has  occurred.  In  severe  cases  when 
extensive  ulceration  exists   and   the  walls  of   the   rectum  are  widely 


Fig.  334. — Kelly's  protoscope. 


Fig.  335. — Pneumatic  proctosigmoidoscope  with  electric  light. 

infiltrated  (a  condition  commonly  found  in  old  syphilitics),  physiologic 
rest  of  the  organ  by  a  temporary  inguinal  colostomy,  and  frequent 
irrigation   of  the  sigmoid  and  rectum  from  above,  are  to  be  recom- 

1  Examination  of  the  interior  of  the  rectum  should  always  be  made  in  suspected 
disease  of  this  portion  of  the  alimentary  canal.  With  the  aid  of  the  Kelly  proctoscope 
or  the  electric  sigmoidoscope  the  bowel  can  be  easily  and  thoroughly  examined  for  a 
distance  of  twelve  or  fifteen  inches.  When  the  short  instrument  is  used,  the  patient 
should  be  in  the  knee-chest  position.  The  longer  tube  may  also  be  employed  while  the 
patient  is  in  Sim's  position  (Figs.  334  and  335). 


728  DISEASES  OF   THE  RECTUM  AND  ANUS 

mended.  In  more  advanced  cases,  where  these  measures  are  ineffec- 
tual, resection  of  the  diseased"  area  is  to  be  advised,  as  in  cases  of 
malignant  disease. 

Ulcer  of  the  Rectum. — Ulcers  of  the  rectum  develop  as  a  result  of 
a  number  of  local  and  constitutional  conditions.  Of  the  former  may 
be  mentioned  trauma  from  hardened  feces,  fish-bones,  or  other  foreign 
bodies;  portal  congestion,  giving  rise  to  hemorrhoidal  ulcers  or  vari- 
cose ulcers  higher  up  in  the  rectum;  dysentery,  chancroidal  disease, 
and  acute  proctitis.  Of  the  constitutional  causes  may  be  mentioned 
tuberculosis,  syphilis,  actinomycosis,  diabetes,  chronic  nephritis,  and 
the  condition  known  as  marasmus.  Carcinomatous  ulcer  will  be  con- 
sidered elsewhere. 

Simple  or  Non-specific  Ulceration. — Simple  or  non-specific  ulceration 
of  the  rectum  is  rare  in  childhood.  It  occurs  most  frequently  in  middle- 
aged  females.  It  is  generally  associated  with  chronic  constipation,  a 
torpid  liver,  and  digestive  disturbances  which  result  in  a  varicose 
condition  of  the  veins  in  the  lower  segment  of  the  rectum.  If  to  this 
be  added  an  abrasion  of  the  mucous  membrane,  infection  takes  place, 
and  an  ulcer  is  formed  with  a  round-cell  infiltration  of  the  submucous 
tissues.  The  process  is  prone  to  extend  in  the  direction  of  the  blood- 
vessels, and  consequently  tends  to  encircle  the  gut.  If  the  ulceration  is 
limited  to  the  mucous  membrane,  recovery  may  occur;  if,  however, 
the  deeper  tissues  are  involved  in  the  destructive  process,  healing  may 
result  in  marked  stenosis  of  the  canal,  a  condition  which  has  been 
described  as  fibrous  stricture. 

Chancroidal  Ulcers. — Chancroidal  ulcers  are  exceedingly  rare  in  this 
country.  They  occur  most  commonly  about  the  anus,  rarely  above 
the  sphincter  muscle.  In  debilitated  subjects  they  may  spread  rapidly 
and  cause  great  destruction  of  tissue. 

Tuberculous  Ulcers. — Tuberculous  ulcers  are  almost  always  secondary 
to  tuberculous  disease  elsewhere.  They  occur  most  frequently  at  or 
near  the  anal  orifice,  and  are  frequently  associated  with  fistula3  and 
marginal  perianal  ulcerations.  When  limited  to  the  interior  of  the 
bowel,  they  occur  as  single  or  multiple  oval,  punched-out  ulcerations 
with  overhanging  edges,  which  may  coalesce,  forming  large  irregular- 
shaped  losses  of  tissue.  In  the  upper  part  of  the  rectum  they  generally 
surround  the  gut. 

Syphilitic  Ulcers. — Syphilitic  ulcers  are  usually  tertiary,  are  caused 
by  a  breaking  down  of  gummatous  masses,  and  may  give  rise  to  great 
destruction  of  tissue.  They  occur  low  down  in  the  rectum,  and  are 
generally  followed  by  a  contracting  scar  which  results  in  obstinate 
stricture.  Tuttle  calls  attention  to  the  fact  that  such  ulcerations  are 
frequently  associated  with  a  peculiar  dry  and  brittle  condition  of  the 
anal  mucous  membrane. 

Primary  and  secondary  syphilitic  lesions  may  also  be  found  in  the 
rectum,  but  rarely  produce  destructive  ulcers.  Mixed  infection  may 
occur  in  syphilitic  ulcerations,  and  the  resulting  strictures  may  differ 
in  no  way  from  those  resulting  from  simple  ulcerations. 


IXJURIES  AND  DISEASES  OF   THE  RECTUM   AND  ANUS     729 

The  ulcers  resulting  from  actinomycosis  are  generally  associated 
with  extensive  infiltrations  of  the  perirectal  tissues. 

Symptoms. — Ulcers  of  the  rectum  from  whatever  cause  usually 
give  rise  to  certain  well-marked  symptoms.  Pain  is  generally  present, 
more  particularly  in  idcers  situated  low  down  within  the  grasp  of  the 
sphincter  muscle.  If  high  up  in  the  rectum,  the  pain  is  often  of  an 
aching  character,  and  may  be  referred  to  the  penis,  neck  of  the  bladder, 
or  coccyx.  Tuberculous  and  syphilitic  ulcers,  as  a  rule,  give  rise  to 
less  acute  pain  than  the  other  varieties.  Diarrhea,  with  the  passage 
of  mucus  and  blood,  is  not  infrequent.  The  diarrhea  is  most  marked 
in  the  morning,  and  rarely  disturbs  the  patient  at  night.  Relaxation 
of  the  sphincter  is  a  symptom  in  some  cases.  In  all  suspected  cases 
the  diagnosis  should  be  confirmed  by  an  ocular  examination  by  means 
of  the  proctoscope.    . 

Treatment. — Simple  hemorrhoidal  or  varicose  ulcers  should  be  treated 
by  rest  in  bed,  frequent  irrigation  of  the  rectum  with  warm  saline 
solution,  and  the  local  use  of  astringents  by  injection  or  suppositories. 
Injections  of  glycerite  of  tannin  (1  part  to  20  of  water)  or  of  mild 
solutions  of  silver  nitrate  are  to  be  recommended;  also  suppositories 
of  iodoform  or  tannic  acid.  Chancroidal  ulcers  should  be  touched 
writh  pure  carbolic  or  nitric  acid,  followed  by  irrigation  and  anodyne 
suppositories.  Tuberculous  ulcerations  may  be  curetted  and  dusted 
with  iodoform,  although  many  cases  are  undoubtedly  made  worse  by 
local  measures.  Cod-liver  oil,  creosote,  and  hygienic  measures  should 
be  employed.  In  the  gummatous  stage  of  syphilitic  ulcerations  sal- 
varsan  or  the  internal  administration  of  mercury  and  potassium  iodide 
will  often  be  of  marked  value.  As  in  the  treatment  of  chronic  ulcer 
of  the  leg,  rest  in  the  horizontal  position  will  greatly  facilitate  the 
treatment  of  chronic  rectal  ulcerations. 

Fissures  of  the  Anus. — Fissure  of  the  anus  consists  in  a  small 
longitudinal  ulcer  of  the  mucous  membrane  of  the  anus,  usually 
situated  on  the  posterior  aspect  of  the  orifice  between  the  folds  of  the 
puckered  integument.  It  is  often  concealed  from  view,  and  may  only 
be  seen  by  drawing  the  folds  well  apart  by  the  fingers.  It  is  frequently 
associated  with  hemorrhoids  or  pruritus  ani,  and  is  caused  generally 
by  an  abrasion  from  the  passage  of  hardened  feces. 

Symptoms. — The  symptoms  of  fissure  are  a  severe  burning  pain  im- 
mediately after  defecation,  which  may  persist  for  several  hours,  the 
presence  of  a  slight  mucous  secretion,  and  the  occasional  appearance  of 
a  few  drops  of  blood  after  a  constipated  movement. 

Treatment.— The  treatment  should  consist  in  absolute  cleanliness, 
hot  sitz  baths,  and  stretching  the  sphincter  under  general  anesthesia. 
In  obstinate  cases  incision  along  the  floor  of  the  fissure  with  dilatation 
of  the  sphincter  will  generally  effect  a  cure. 

Pruritus  Ani. — Pruritis  ani  is  an  intolerable  itching  of  the  skin  and 
mucous  membrane  of  the  anal  margin  without  eczema  or  other  cuta- 
neous lesions.  It  occurs  chiefly  at  night,  and  frequently  is  associated 
with  fissure  or  hemorrhoids,  but  may  be  wholly  of  nervous  origin. 


730  DISEASES  OF   THE  RECTUM  AND  ANUS 

Treatment. — The  treatment  should  embrace  measures  to  improve 
the  general  health  and  nervous  tone  of  the  individual,  and  the  local  use 
of  hot  water,  followed  by  the  application  of  a  solution  of  carbolic  acid 
(1  to  100)  on  a  soft  linen  compress. 

In  obstinate  cases  which  have  resisted  all  efforts  at  palliative  treat- 
ment, an  operation,  consisting  of  an  incision  through  skin  and  sub- 
cutaneous tissue,  completely  surrounding  the  anus,  may  be  performed, 
the  object  being  to  divide  the  superficial  cutaneous  nerves  which 
supply  the  anal  region.  After  removing  a  small  segment  of  tissue. 
the  wound  is  resutured,  or  may  be  kept  open  to  heal  by  granulation. 

TUMORS    OF    THE    RECTUM. 

Benign  Tumors. — Of  the  benign  tumors  which  occur  in  the  rectum, 
adenomata  are  the  most  frequent.  They  may  occur  as  single  peduncu- 
lated growths  or  as  multiple  tumors  involving  a  large  extent  of  mucous 
membrane.  The  tumors  are,  as  a  rule,  soft,  freely  movable,  and  if 
situated  low  down  in  the  bowel  may  protrude  through  the  anus. 
Papillomata,  or  villous  tumors,  angiomata,  fibromata,  myxomata,  and 
lipomata,  are  rare.  The  term  rectal  polyp  is  used  clinically  to  describe 
any  soft  pedunculated  benign  tumor  growing  from  the  mucous  mem- 
brane of  the  rectum.  In  the  majority  of  instances  rectal  polyps  are 
found  to  be  adenomata. 

Symptoms. — The  symptoms  of  benign  growths  are  chiefly  those  of  a 
foreign  body  in  the  bowel.  If  the  growth  is  situated  low  enough  to 
engage  in  or  protrude  through  the  sphincter,  pain  and  tenesmus  may 
be  present.  If  ulceration  of  the  mucous  membrane  occurs,  there  may 
be  hemorrhage.  Stenosis  of  the  gut  is  rare,  and  never  gives  rise  to 
complete  obstruction.  In  the  majority  of  instances  benign  tumors 
situated  well  above  the  sphincter  muscles  produce  no  symptoms, 
and  are  discovered  only  as  a  result  of  systematic  rectal  examination 
by  the  finger  or  speculum. 

Treatment. — The  treatment  of  polyps  and  other  small  growths 
should  be  complete  removal,  which  is  easily  accomplished  with  scissors, 
cutting  forceps,  or  the  wire  snare,  if  the  growth  is  accessible.  In 
tumors  involving  a  large  area  of  the  bowel  the  growth  may  be  attacked 
from  behind  by  the  Kraske  procedure,  or  a  resection  may  be  necessary. 

Dermoids. — Dermoids  of  the  rectum  are  rare.  When  they  do  occur 
they  generally  involve  the  posterior  wall  of  the  gut,  and  present,  as 
a  rule,  long  locks  of  hair  which  project  into  the  lumen  of  the  bowel 
and  may  protrude  through  the  anal  orifice.  Dermoids  occurring 
between  the  rectum  and  sacrum  and  coccyx  (postrectal  dermoids) 
are  more  common  and  attain  a  larger  size.  They  may  develop  below 
or  above  the  levator  ani  muscle.  Those  which  develop  below  the 
muscle  arise,  as  a  rule,  from  the  anococcygeal  body,  the  remnant  of 
the  neurenteric  canal.  They  are  often  spoken  of  as  thyrodermoids  on 
account  of  their  resemblance  in  structure  to  thyroid  tissue  (Fig.  336). 


TUMORS  OF  THE  RECTUM  7.31 

Those  which  develop  above  the  muscle  often  reach  an  enormous 
size.    As  a  rule,  they  contain  pultaceous  material,  hair,  and  teeth. 

Treatment. — The  treatment  of  dermoids  not  involving  the  rectal 
wall  is  by  enucleation  after  exposure  of  the  cyst  wall.  In  those  involv- 
ing the  wall  of  the  gut  partial  excision  will  be  necessary.  The  best 
exposure  in  these  cases  is  to  be  obtained  by  the  sacral  operation 
described  under  the  treatment  of  malignant  neoplasms  of  the  rectum. 

Malignant  Tumors. — Carcinoma. — Carcinoma  of  the  rectum  is  a 
fairly  common  disease.  Tuttle  states  that  nearly  5  per  cent,  of  all 
cancerous  growths  occur  in  the  sigmoid,  rectum,  and  anal  region.  The 
disease  presents  several  distinct  varieties.  Thus  epithelioma  occurs 
at  the  junction  of  the  skin  and  mucous  membrane  at  the  anus,  and 
differs  in  no  respect  from  superficial  epithelioma  elsewhere.  Adeno- 
carcinoma is  the  conlmonest  variety  found  within  the  bowel.  Xext  in 
frequency  comes  scirrhus,  the  hard  fibrous  constricting  growth;  and 
lastly,  the  medullary  or  the  very  cellular  variety.    Cancer  of  the  rectum 


Fig.  336. — Anococcygeal  dermoid. 

is  a  disease  of  late  middle  life,  occurring  most  frequently  in  individuals 
between  forty  and  sixty  years  of  age.  It  is  slightly  more  common  in 
men  than  in  women.  In  the  majority  of  instances  it  is  located  in  the 
upper  part  of  the  rectum.  Tuttle's  tables  show  that  5b  per  cent,  of 
the  cases  occur  in  the  supraperitoneal  portion,  IS  per  cent,  in  the 
infraperitoneal  portion,  15  per  cent,  in  the  sigmoid,  and  9  per  cent. 
at  the  anus. 

Metastasi>  takes  place  through  the  lymphatics,  at  an  early  period 
in  the  more  cellular  growths,  later  in  the  fibrous  and  adenomatous 
varieties.  The  iliac  and  lumbar  nodes  are  chiefly  enlarged;  the 
inguinal  also  if  the  disease  involves  the  anus. 

Symptoms. — The  symptoms  of  cancer  of  the  rectum  resemble  at 
first  those  of  hemorrhoids  or  ulcer,  if  the  di-ease  is  situated  in  the 
lower  segment  of  the  tube.  Thus  there  is  more  or  less  constipation 
deep-seated  pain,  hemorrhage,  and  tenesmus.  If  the  growth  is  located 
higher  up,  the  first  symptoms  are  often  those  of  stricture.  The 
patient  experiences  more  and  more  difficulty  in  obtaining  a  satisfac- 


732  DISEASES  OF   THE  RECTUM  AXD  ANUS 

tory  movement  of  the  bowels,  with  or  without  occasional  pain  and 
discomfort.  Later,  attacks  of  incomplete  obstruction  occur,  with 
pain  and  general  abdominal  distention,  which  are  usually  relieved 
by  cathartics  and  enemata.  The  stools  become  progressively  smaller 
in  size  and  amount,  and  the  mass  of  retained  fecal  matter  above  the 
constriction  may  occasion  irritation  resulting  in  recurrent  attacks 
of  enteritis,  during  which  diarrhea  may  be  present,  with  the  passage 
of  mucus  and  blood.  Thin,  ribbon-shaped  stools  are  occasionally 
observed  if  the  growth  is  near  the  anus. 

Diagnosis. — The  diagnosis  generally  can  be  made  by  digital  exami- 
nation if  the  growth  is  accessible,  by  the  proctoscope  if  beyond  the 
reach  of  the  finger.  To  the  examining  finger  the  growth  generally 
gives  the  impression  of  a  dense  nodular  mass  involving  all  the  coats 
of  the  rectum.  In  many  cases  the  growth  completely  surrounds  the 
bowel,  constricting  the  lumen  to  a  small  size.  The  edges  of  the  con- 
striction are  frequently  ulcerated  and  bleed  easily  when  touched. 

Progressive  anemia,  loss  of  weight,  and  cachexia  occur  in  this  as  in 
other  cancerous  affections,  and  metastases  appear  in  the  liver  and  other 
organs. 

Sarcoma. — Sarcoma  of  the  rectum  is  a  rare  disease.  It  attacks  by 
preference  the  lower  segment  of  the  organ,  and  arises  in  the  submucous 
cellular  coat.  As  in  other  situations,  it  presents  varying  degrees  of 
malignancy  according  to  the  rapidity  of  its  growth  and  its  histologic 
characteristics.  The  growth  of  a  spindle-cell  sarcoma  may  be  com- 
paratively slow,  and  recovery  may  follow  its  complete  removal. 
Lymphosarcoma,  on  the  other  hand,  is  generally  fatal  in  a  few  months 
after  the  diagnosis  is  made,  in  spite  of  any  and  all  treatment. 

Diagnosis. — The  diagnosis  usually  can  be  made  by  observing  the 
rapidity  of  the  growth,  its  situation  in  the  lower  segment  of  the  gut, 
the  fact  that  the  mucous  membrane  is  at  first  freely  movable  over  the 
tumor  mass,  and  by  the  absence  of  stenosis.  In  ulcerating  soft  sar- 
comata hemorrhage  may  be  profuse. 

Treatment  of  Malignant  Tumors  of  the  Rectum. — Epithelioma  of 
the  anus,  when  limited  in  extent,  should  be  thoroughly  excised  and 
the  mucous  membrane  of  the  bowel  drawn  downward  and  stitched 
to  the  cutaneous  margins;  if  more  extensive,  the  disease  should  be 
attacked  from  behind  by  the  Kraske  method,  soon  to  be  described, 
and  the  lower  portion  of  the  bowel,  the  sphincter  muscle,  and  a  large 
area  of  surrounding  skin  removed.  The  healthy  intestine  should 
then  be  brought  downward  and  a  new  anus  formed  either  at  the  site 
of  the  old  one  or  at  a  higher  point  through  the  sacral  opening.  In 
women  a  fair  exposure  of  the  lower  segment  of  the  rectum  often  can 
be  made  by  a  longitudinal  division  of  the  posterior  vaginal  wall. 

In  the  presence  of  malignant  disease  in  the  upper  rectum  or  iigmoid 
four  methods  may  be  employed: 

First. — Extirpation  of  the  lower  rectum  by  the  sacral  route  (Kraske). 
This  consists  in  removal  of  the  coccyx  and  a  part  (Hochenegg),  or 


TUMORS  OF  THE  RECTI M  733 

the  whole  (Bardenhauer),  of  the  lower  one  or  two  segments  of  the 
sacrum,  separating  the  rectum  from  the  surrounding  tissues,  removing 
the  diseased  area,  and  uniting  the  proximal  and  distal  portions  with 
two  or  more  rows  of  sutures;  or  removal  of  the  entire  lower  segment 
of  the  organ  and  creating  a  sacral  anus.  In  this  operation  the  upper 
portion  of  the  rectum  and  a  part  of  the  sigmoid  often  can  be  brought 
down  into  the  wound  by  opening  the  peritoneal  cavity  and  severing 
all  of  the  peritoneal  attachments  except  the  mesentery. 

When  it  seems  desirable  completely  to  remove  the  lower  portion  of 
the  rectum  and  create  a  sacral  anus,  the  upper  segment  of  the  bowel 
should  be  drawn  outward  at  the  upper  angle  of  the  incision,  rotated 
on  its  longitudinal  axis  for  about  180  degrees,  and  stitched  to  the 
cutaneous  wound.  After  recovery  from  the  operation  this  orifice 
can  be  guarded  by  a  specially  constructed  truss  with  a  pneumatic 
rubber  ring. 

Second. — The  abdominal  or  combined  operation  for  growths  in 
the  upper  rectum  or  lower  sigmoid.  The  patient  should  be  placed 
in  the  Trendelenburg  posture  and  the  abdominal  cavity  opened  by 
a  median  incision  extending  from  the  umbilicus  to  the  symphysis. 
The  intestines  are  drawn  upward  and  retained  by  large  gauze 
pads,  leaving  the  pelvic  cavity  well  exposed.  The  area  of  the 
disease  is  next  appreciated  and  the  presence  or  absence  of  enlarged 
lymph  nodes  noted.  An  incision  is  then  made  along  the  left  border 
of  the  mesentery,  dividing  the  peritoneum  only.  This  should  extend 
upward  to  the  region  of  the  inferior  mesenteric  artery  and  all 
enlarged  lymph  nodes  and  surrounding  areolar  tissue  removed.  This 
is  easily  accomplished  by  gently  stripping  the  subperitoneal  tissues 
from  the  muscles  by  a  gauze  sponge  as  the  bowel  is  being  drawn  over 
toward  the  median  line,  care  being  taken  to  avoid  the  ureter  and 
superior  hemorrhoidal  vessels.  The  bowel  is  then  clamped  and  divided 
well  above  and  below  the  diseased  area  and  the  proximal  and  distal 
extremities  inverted  and  closed  by  purse-string  sutures.  The  diseased 
portion  is  next  removed  with  the  lymph  nodes  and  areolar  tissue,  the 
two  closed  segments  of  the  bowel  approximated  and  a  lateral  anasto- 
mosis performed.  When,  on  account  of  the  low  situation  of  the  growth, 
this  anastomosis  is  impossible,  an  effort  should  be  made  to  draw  the 
upper  segment  of  the  gut  downward  sufficiently  to  reach  the  anal 
orifice.  If  this  is  difficult  or  impossible,  the  descending  colon  can  be 
still  further  freed  by  ligature  and  division  of  the  superior  hemorrhoidal 
artery  near  its  origin,  or  even  of  the  inferior  mesenteric  trunk,  as 
recently  suggested  by  Moynihan;  the  circulation  in  the  lower  por- 
tion of  the  sigmoid  being  carried  on  by  a  long  arterial  loop  which 
runs  parallel  with  the  intestine  and  joins  a  similar  loop  from  the 
colica  media.  When  the  upper  loop  is  sufficiently  mobilized,  the 
peritoneum  passing  from  the  floor  of  the  pelvis  to  the  rectum  is  divided 
and  the  bowel  separated  from  the  levator  muscle  well  down  into  the 
ischiorectal  fossa.    The  patient  is  next  placed  in  the  lithotomy  posi- 


734  DISEASES  OF   THE  RECTUM   AND  ANUS 

tion,  and  an  incision  made  to  the  left  of  the  anus  sufficiently  long  to 
enable  an  assistant  to  still  further  separate  and  draw  downward  the 
rectal  stump,  which  is  finally  inverted  through  the  anus  and  cut  off, 
care  being  taken  to  leave  the  sphincter  muscle  intact.  A  long-bladed 
forceps  is  next  passed  upward  through  the  now  denuded  sphincter 
and  the  upper  loop  of  sigmoid  drawn  downward  and  stitched  to  the 
cutaneous  margin  of  the  anus.  The  last  step  in  the  operation  is  to 
unite  the  peritoneum  about  the  transplanted  sigmoid,  close  the  abdom- 
inal cavity,  and  insert  a  large  mass  of  gauze  for  drainage  in  the  perineal 
wound.  This  operation  has  been  practically  abandoned  by  surgeons 
on  account  of  its  high  mortality  and  the  fact  that  gangrene  of  the 
lower  portion  of  the  transplanted  sigmoid  is  of  frequent  occurrence. 
A  safer  operation  is  the  following : 

Third. — Complete  removal  of  the  lower  segment  of  the  bowel  and 
the  formation  of  an  inguinal  anus.  Perform  a  laparotomy  as  in  the 
preceding  operation,  expose  the  disease,  follow  up  and  remove  the 
lymphatics  to  the  junction  of  the  inferior  mesenteric  artery  and  aorta. 
Next  divide  the  sigmoid  well  above  the  growth,  close  both  ends  with 
purse-string  sutures,  and  draw  the  upper  loop  outward  through  an 
intermuscular  opening  near  the  anterior  superior  spine,  where  it  is 
fixed  by  two  or  three  cutaneous  sutures.  The  position  of  the  patient  is 
next  changed  as  indicated  above,  the  anus  surrounded  by  an  elliptical 
incision,  which  is  extended  backward  to  the  coccyx,  the  entire  lower 
segment  of  the  bowel  is  then  freed  from  its  attachments  and  removed 
with  its  mesentery  and  all  infected  lymph  nodes  and  areolar  tissue  in 
the  manner  just  described,  after  which  the  peritoneum  of  the  floor  of 
the  pelvis  is  united  and  the  abdominal  wound  closed.  The  protruding 
end  of  the  bowel  should  not  be  opened  until  the  following  day,  after 
adhesions  have  formed,  which  completely  shut  off  the  peritoneal  cavity. 

Fourth. — The  fourth  method,  applicable  to  cases  demanding  complete 
excision  of  the  entire  lower  segment,  and  whose  condition  contra- 
indicates  the  performance  of  a  one-stage  abdominoperineal  resection 
with  the  formation  of  a  permanent  inguinal  anus,  is  the  two-stage 
operation;  the  first  stage  consisting  of  an  incision  through  the  left  rectus, 
with  exploration  of  the  abdomen  for  possible  metastases  in  the  liver, 
retroperitoneal  glands,  or  other  structures,  this  step  being  completed 
by  the  formation  of  an  abdominal  colostomy;  the  second  stage  being 
performed  ten  days  or  two  weeks  later,  and  consisting  in  the  complete 
excision  of  the  rectum  by  the  posterior  or  Kraske  route;  purse-string 
closure  of  the  sigmoid  distal  to  the  colostomy  opening,  closure  and 
drainage  of  the  posterior  wound.  This  method  has  been  recently 
advocated  and  employed  largely  by  a  number  of  American  and 
European  surgeons. 

While  rectal  cancer  has,  in  the  past,  been  justly  regarded  by  surgeons 
as  an  almost  hopeless  condition,  the  report  of  a  recent  series  of  100 
cases  by  Tuttle,  with  an  operative  mortality  of  13  per  cent,  and  26 
per  cent,  of  cures  three  years  after  operation,  gives  much  encourage- 


TUMORS  OF  THE  RECTUM  735 

ment,  and  shows  the  effect  of  the  modern  more  radical  methods  of 
operation.  In  a  certain  percentage  of  cases,  however,  the  surgeon  is 
not  consulted  Until  the  disease  is  so  far  advanced  as  to  be  inoperable. 
A  large  measure  of  comfort  can  be  given  to  these  unfortunate  indi- 
viduals by  colostomy,  which  diverts  the  intestinal  current,  lessens  the 
pain,  and  removes  the  distressing  tenesmus. 

Hemorrhoids. — Hemorrhoids  or  piles,  is  a  varicose  dilatation  of 
one  or  more  of  the  veins  in  the  lower  portion  of  the  rectal  mucous 
membrane.  The  hemorrhoidal  plexus  is  formed  by  a  large  number  of 
veins  which  originate  in  small  dilated  pools  or  spaces  located  in  the 
submucous  tissue  just  above  the  anorectal  junction.  Each  of  these 
in  health  is  about  the  size  of  a  grain  of  wheat,  and  gives  origin  to  a 
vein  which  passes  upward,  freely  anastomosing  with  its  numerous 
fellows,  and  eventually  piercing  the  muscular  coat  of  the  bowel  about 
three  inches  above  the  anus,  to  enter  the  radicals  of  the  portal  system. 
From  the  lower  extremity  of  these  small  pools,  minute  anastomosing 
branches  emerge  which  empty  into  the  external  hemorrhoidal  veins 
located  immediately  under  the  integument  at  the  anal  orifice  (Tuttle). 

Under  conditions  of  portal  congestion  from  chronic  constipation, 
congested  liver,  cirrhosis,  valvular  disease  of  the  heart,  etc.,  these 
small  veins  become  engorged,  and  permanent  dilatation  results.  If 
the  dilatation  is  limited  to  the  external  hemorrhoidal  veins,  the  con- 
dition is  described  as  one  of  external  piles;  if  limited  to  the  small 
venous  pools  within  the  rectum,  it  is  spoken  of  as  internal  piles;  if 
both  are  involved  in  the  process,  the  term  mixed  piles  is  employed. 
In  any  of  these  situations  thrombosis  may  occur,  giving  rise  to  bluish 
oval  indurated  masses,  thrombotic  piles,  or  infection  may  be  added, 
giving  rise  to  a  condition  of  localized  phlebitis,  or  inflamed  piles. 
Occasionally  a  cluster  of  internal  piles  will  be  forced  outward  through 
the  sphincter  muscle,  and  by  its  contraction  the  mass  becomes  strang- 
ulated. Such  masses  often  resemble  a  miniature  bunch  of  grapes, 
and  if  not  quickly  reduced  ulceration  or  sloughing  may  result. 

Symptoms. — Chronic  dilatation  of  the  hemorrhoidal  veins  is  un- 
doubtedly present  in  many  individuals  without  causing  symptoms. 
In  certain  cases,  however,  there  is  a  sense  of  weight  and  pain  in  the 
rectum,  accentuated  by  defecation.  This  may  persist  for  one  or  more 
hours  and  prevent  sleep.  If  the  cluster  of  internal  hemorrhoids  is 
large,  the  patient  may  experience  a  feeling  of  a  foreign  body  in  the 
rectum,  which  is  not  relieved  by  defecation.  Hemorrhage  due  to 
superficial  ulceration  is  a  fairly  constant  symptom  in  internal  piles, 
and  in  many  cases  it  is  profuse. 

If  a  mass  of  internal  piles  becomes  strangulated,  or  if  thrombosis 
and  infection  occur,  the  pain  is  greatly  increased  in  severity,  and  is 
accompanied  by  local  tenderness  and  fever.  All  of  these  symptoms  are 
aggravated  by  defecation,  walking,  or  sitting.  The  patient  is  confined 
to  his  bed,  and  often  experiences  great  suffering  for  several  days.  An 
individual  in  this  condition  is  generally  spoken  of  as  "having  an  attack 


736  DISEASES  OF   THE  RECTUM  AND  ANUS 

of  piles."  As  a  rule,  the  symptoms  subside  after  a  few  days  under 
appropriate  treatment.  In  exceptional  cases  general  infection  may 
occur  from  disintegration  of  the  septic  thrombus  and  dissemination 
by  the  circulation.  There  is  a  popular  impression  that  itching  is  a 
symptom  of  piles.  While  this  symptom  is  frequently  associated  with 
piles,  it  is  rarely  due  to  the  venous  dilatation,  but  rather  to  an  asso- 
ciated fissure,  eczema,  or  pruritus.  Intense  itching  is  said  to  be 
occasionally  caused  by  the  small  thick  skin-tabs  so  frequently  seen 
about  the  anus  in  individuals  whose  external  piles  have  been  spon- 
taneously cured  by  thrombosis  and  obliteration  of  the  vessels. 

The  diagnosis  is  easily  made  by  inspection  of  the  parts,  drawing 
aside  the  folds  of  the  anus,  and  instructing  the  patient  to  bear  down. 
By  this  method  not  only  the  external  piles  are  made  prominent  and 
filled  with  blood,  but  also  the  lower  portions  of  the  internal  hemor- 
rhoids are  brought  into  view.  Unless  the  veins  are  inflamed,  greatly 
thickened,  or  contain  thrombi,  they  cannot  be  appreciated  by  digital 
examination.  Examination  by  the  short  proctoscope  in  the  knee- 
chest  position  is  often  negative,  for  the  reason  that  in  this  position  the 
veins  are  emptied  and  collapsed. 

Treatment. — The  tendency  to  hemorrhoids  should  be  combated  by 
exercise,  restricted  diet,  and  measures  to  avoid  constipation  and  portal 
congestion. 

Strangulated  or  inflamed  piles  should  be  treated  by  hot  sitz  baths, 
rectal  irrigations  when  they  are  possible,  moderate  catharsis,  and  the 
local  application  of  soothing  ointments  or  poultices.  If  the  condition 
is  not  such  as  to  confine  the  patient  to  the  bed,  the  following  prescrip- 
tion will  be  found  serviceable:     " 

Ung.  gallae, 

Ung.  stramonii,  aa      3j 

Sig.— Apply  morning  and  night. 

Thrombosed  and  infected  external  piles  are  often  promptly  cured 
by  incision,  turning  out  the  clot,  and  packing  the  wound  with  sterile 
gauze. 

The  radical  treatment  of  hemorrhoids  consists  in  three  procedures: 
obliteration  of  the  lumen  of  the  vein  by  the  injection  of  carbolic  acid; 
removal  of  the  individual  tumors;  or  removal  of  the  pile-bearing  area 
of  the  rectal  mucous  membrane. 

The  injection  method  is  largely  employed  by  irregular  practitioners, 
often  with  excellent  results.  It  has  the  advantage  that  it  allows  the 
patient  to  be  up  and  about  during  treatment.  It  consists  in  the  in- 
jection of  from  3  to  10  drops  of  a  20  per  cent,  solution  of  carbolic  acid 
into  the  centre  of  the  pile.  The  parts  should  be  thoroughly  disinfected 
and  the  needle  introduced  from  below  at  a  point  where  the  hemorrhoid 
joins  the  healthy  mucous  membrane. 

Tuttle  recommends  the  following  formula: 


TUMORS  OF  THE  RECTUM 


737 


Acid,  carbolici  (Cal verts), 
Acid,  salicylici, 
Sodii  boratis, 
Glycerine  (sterile), 


5ij 

3ss 

3i 
5j— M. 


The  immediate  result  of  the  injection  is  to  cause  a  painful  swelling 
of  the  pile,  which  subsides  in  two  or  three  days,  leaving  only  a  thickened 
area  of  mucous  membrane. 


Fig.  337. — Angiotribe. 

Removal  of  the  individual  tumors  is  accomplished  by  several 
methods.  In  all,  the  patient  should  be  anesthetized  and  placed  in 
the  lithotomy  position.  The  sphincter  should  then  be  thoroughly 
stretched,  temporarily  paralyzing  its  fibres. 

The  simplest  method  of  removal  is  by  crushing  the  pile  with  the 
angiotribe  (Fig.  337).  The  method  by  ligation  and  excision  is  the 
one  most  generally  employed  in  this  country.  The  pile  is  grasped 
by  a  pair  of  forceps  and  drawn  downward.    Its  base  is  next  encircled 


Fig.  338.— Smith  clamp. 

by  a  cut  which  divides  only  the  mucous  membrane.  A  straight 
needle  threaded  with  heavy  silk  is  then  passed  through  the  base  of  the 
tumor  and  securely  tied  above  and  below,  care  being  taken  to  avoid 
including  in  the  knot  any  of  the  rectal  mucous  membrane.  The  sum- 
mit of  the  pile  is  then  removed  with  scissors.  The  method  by  the 
clamp  and  cautery  consists  in  grasping  the  summit  of  the  pile  by  a 
pair  of  toothed  forceps,  drawing  it  well  downward  and  applying  a 
47 


7:;s 


DISEASES  OE   THE  RECTUM  AND  A.XCS 


Smith  clamp  (Fig.  338)  at  the  base.  The  summit  of  the  tumor  is  then 
removed  with  scissors  and  the  stump  slowly  cauterized  with  a 
cherry-red  Paquelin  point. 

After  any  of  these  methods  a  gauze-covered  spool-shaped  rectal 
tube  should  he  introduced  and  held  in  position  by  four  tape  bands 
(Fig.  339).  This  prevents  hemorrhage  and  allows  the  escape  of  flatus. 
It  should  be  removed  on  the,  fourth  day  and  the  bowel  injected  daily 
for  one  week  with  a  solution  of  glycerite  of  tannin  (1  to  20). 

Removal  of  the  entire  pile-bearing  area  of  the  rectal  mucous  mem- 
brane (Whitehead's  operation)  consists  in  making  a  circular  incision 
;it  the  margin  of  the  mucous  membrane  and  skin  of  the  anus,  separat- 
ing the  mucous  membrane  from  the  muscular  coat  for  a  distance  of 
from  two  to  three  inches,  then  cutting  off  the  pile-bearing  membrane, 
and  suturing  the  healthy  mucosa  to  the  skin.  This  operation  may  be 
relied  upon  to  cure  the  piles,  but  it  has  the  disadvantage  that  it  re- 
moves that  portion  of  the  mucous  membrane  which  contains  the 


Fig.  339.— Rectal  tube. 


sensory  nerves  entering  into  what  may  be  called  the  anal  reflex,  or 
the  involuntary  tightening  of  the  anal  orifice  when  the  sensation  of 
solid  matter,  fluid,  or  gas  is  felt  in  the  lower  rectum.  The  writer  has 
seen  several  patients  in  whom  rectal  incontinence  was  present,  yet  who 
seemed  to  possess  the  ability  voluntarily  to  contract  the  sphincter 
as  well  as  before  operation.  Another  objection  to  the  operation  is  the 
possibility  of  infection,  sloughing,  and  retraction  of  the  mucous  mem- 
brane, leaving  a  large  circular  granulating  area  which  heals  slowly  and 
is  invariably  followed  by  a  dense  stricture. 

Prolapse  of  the  Rectum. — Prolapse  of  the  rectum  is  a  projection 
downward  of  the  mucous  membrane  of  the  bowel  through  the  anal 
orifice.  This  occurs  to  a  slight  extent  in  healthy  individuals  during 
a  constipated  movement.  The  membrane,  however,  is  quickly  drawn 
upward  by  contraction  of  the  sphincter,  and  no  untoward  symptoms 
are  produced. 

If  more  of  the  mucous  membrane  is  prolapsed,  and  it  is  not  imme- 


TUMORS  OF  THE  RECTUM  739 

diately  replaced  by  contraction  of  the  sphincter,  the  condition  is  called 
prolapsus-  ani.  If  the  disease  progresses  and  the  entire  wall  of  the  gut 
is  protruded,  the  condition  is  spoken  of  as  prolapsus  recti. 

The  disease  is  more  common  in  children  than  in  adults,  and  is  caused 
by  constipation,  severe  rectal  or  bladder  tenesmus  from  any  cause,  the 
presence  of  hemorrhoids  or  other  rectal  tumors,  and  from  general 
weakness  and  muscular  relaxation.  In  the  early  stages  reduction  is 
readily  effected  by  gentle  pressure  with  the  fingers.  In  the  later  stages 
the  prolapsed  bowel  becomes  much  thickened,  and  when  reduced  shows 
a  strong  tendency  to  reappear. 

Diagnosis. — The  diagnosis  is  easily  made  by  observing  the  presence 
of  an  oblong,  sausage-shaped,  pink  or  bluish  mass  protruding  from  the 
anus. 

Treatment. — The  treatment  should  consist  in  removal  of  the  cause 
when  this  is  possible,  the  use  of  astringent  injections,  and  the  habitual 
employment  of  a  commode  so  constructed  that  the  seat  is  made  to 
slant  from  behind  forward  at  an  angle  of  thirty  or  forty  degrees  from 
the  horizontal.  This  prevents  the  patient  assuming  a  position  in  which 
excessive  straining  is  possible. 

If  these  measures  fail,  linear  cauterization  of  the  rectal  mucous 
membrane  for  a  distance  of  two  or  three  inches  above  the  sphincter 
is  to  be  advised.  This  should  be  done  under  general  anesthesia, 
the  Paquelin  cautery  being  employed,  and  three  or  four  deep  eschars 
made  equidistant  from  each  other.  In  children  the  cauterization  may 
be  accomplished  by  the  application  of  pure  carbolic  acid  to  the  pro- 
lapsed bowel  by  means  of  a  glass  rod  or  pointed  stick.  When  the  acid 
has  produced  its  effect,  it  should  be  washed  off  with  alcohol  and  salt 
solution,  after  which  the  prolapse  should  be  replaced  and  the  bowels 
confined  for  two  or  three  days.  Recurrence  should  be  prevented  by 
the  use  of  laxatives,  enemata,  and  the  slanting-seat  commode.  In 
obstinate  cases  of  prolapse  of  the  mucous  membrane  the  Whitehead 
operation  described  on  page  738  has  been  recommended;  also  excision 
of  a  portion  of  the  rectum.  These  methods,  however,  are  inferior  to 
sigmoidopexy,  or  the  Moschowitz  operation.  The  former  consists  in 
opening  the  abdomen  by  means  of  the  intermuscular  method,  in  the 
left  inguinal  region,  drawing  the  sigmoid  well  upward  and  attaching 
its  mesentery  to  the  peritoneum  and  iliac  fascia  by  means  of  two  or 
three  chromicized  catgut  sutures. 

Moschowitz  approaches  the  problem  of  prolapse  of  the  rectum 
from  a  different  standpoint,  considering  it  a  true  hernia,  the  sac  of 
which  is  formed  by  the  cul-de-sac  of  Douglas  which,  with  its  contents 
of  small  intestine,  pushes  downward  the  anterior  wall  of  the  rectum 
until  finally  it  protrudes  through  the  anus,  the  greater  portion  of  the 
prolapsed  tissue  being  formed  by  the  anterior  wall  of  the  rectum  and 
not  the  posterior. 

With  this  conception  of  the  pathology,  he  has  devised  an  operation 
which  consists  in  obliteration  of  the  cul-de-sac  of  Douglas  through  a 


740  DISEASES  OF  THE  RECTUM  AND  ANUS 

median  laparotomy  wound.  With  the  patient  in  a  high  Trendelenburg 
position,  and  the  abdomen  opened,  the  rectum  is  pulled  upward  a 
far  as  possible,  and  a  series  of  sutures  placed  purse-string  fashion  to 
obliterate  the  cul  de  sac,  commencing  near  the  bottom  and  carried 
upward  as  high  as  the  posterior  surface  of  the  uterus,  in  the  female, 
or  the  base  of  the  bladder,  in  the  male.  Laterally,  the  suture  includes 
the  pelvic  fascia  and  posterolateral  wall,  and  anterior  walls  of  the 
rectum. 

Care  must  be  taken  to  avoid  injury  to  the  ureters  or  to  the  iliac 
vessels.  This  procedure  not  only  obliterates  the  cul-de-sac  and  keeps 
the  intestine  out  of  the  pelvis,  but  also  serves  to  anchor  the  rectum 
and  the  cul  de  sac  to  the  pelvic  fascia  laterally.  No  attempt  is  made 
to  do  anything  to  the  protruding  mucous  membrane.  The  results 
of  this  operation  have  been  most  satisfactory  in  cases  of  true  prolapse 
in  which  all  the  layers  of  the  rectal  wall  are  involved. 


CHAPTER  XXVII. 
DISEASES  OF  BONE. 

INFLAMMATION    OF   BONE. 

Acute  Osteomyelitis. — Acute  osteomyelitis  is  an  infectious  inflam- 
mation of  bone.  The  older  surgeons  were  accustomed  to  describe 
three  varieties  of  the  disease:  periostitis,  or  inflammation  of  the  peri- 
osteum; osteitis,  or  inflammation  of  the  denser  portion  of  the  bone; 
and  osteomyelitis,  or  inflammation  of  the  bone-marrow  and  cancellous 
tissue.  A  better  understanding  of  the  pathology  of  the  affection, 
however,  has  demonstrated  that  these  are  simply  different  stages  of 
the  same  pathologic  process,  which  at  one  time  or  another  generally 
involves  all  of  the  structures  of  bone.  Septic  processes  in  bone  differ 
in  no  respect  from  similar  processes  in  the  soft  parts,  except  in  so  far 
as  their  symptoms  and  results  may  be  modified  by  the  unyielding 
nature  of  the  tissue. 

Two  forms  of  the  disease  are  described,  the  traumatic  and  the 
non-traumatic  or  idiopathic.  The  former  variety  occurs  obviously 
at  any  age;  the  latter  is  commonest  in  children  and  young  adults. 
The  cause  of  acute  osteomyelitis  is  invariably  the  invasion  of  the  tis- 
sues by  pathogenic  micro-organisms,  either  through  a  wound  exposing 
and  injuring  the  bone,  through  the  blood  current,  or  through  the 
lymphatics.  Of  the  various  micro-organisms  which  may  give  rise  to 
osteomyelitis,  Staphylococcus  pyogenes  aureus  is  the  one  most  frequently 
found;  the  others  in  the  order  of  their  frequency  being  the  strepto- 
coccus, the  pneumonococcus,  the  typhoid  or  colon  bacillus.  The  pro- 
cess may  begin  in  any  part  of  the  bone;  but  in  the  non-traumatic 
or  so-called  idiopathic  cases  the  infection  usually  first  occurs  in  the 
interior,  and  in  the  majority  of  instances  near  the  most  active  epiphysis. 
The  first  result  of  the  microbic  invasion  is  a  reactionary  hyperemia 
and  the  occurrence  of  an  inflammatory  exudate.  Owing  to  the  un- 
yielding nature  of  the  tissues  this  at  once  produces  sufficient  pressure 
greatly  to  impede  or  totally  arrest  the  circulation,  and  a  more  or  less 
extensive  necrosis  of  the  ischemic  tissue  takes  place.  If  the  area  of 
necrosis  is  small  and  limited  to  the  thin  cancellous  structure  and 
bone-marrow,  a  circumscribed  focus  of  suppuration  results  (bone- 
abscess).  At  a  later  period  this  abscess,  unless  relieved,  becomes  sur- 
rounded by  a  layer  of  dense  bony  tissue,  forming  a  protecting  capsule. 
In  rare  instances  this  sclerosis  may  extend  and  involve  a  large  part 
of  the  shaft  of  the  bone.  When  the  disease  involves  a  large  area,  as 
the  diaphysis  of  a  long  bone,  the  pus  rapidly  extends  in  the  direction 


742  DISEASES  OF  BONE 

of  least  resistance,  which  is  along  the  medullary  canal  (Plate  XXII). 
A  barrier  is  reached  at  the  epiphysis,  as  septic  inflammations  rarely 
pass  this  point.  The  infection,  as  a  rule,  burrows  outward  through 
the  cortex,  and  often  just  beneath  the  epiphyseal  cartilage  until  the 
external  surface  of  the  bone  is  reached.  Here  it  may  give  rise  to  sup- 
puration, which  spreads  rapidly  beneath  the  periosteum,  separating 
it  from  the  bone  (subperiosteal  abscess),  and  when  the  tension  causes 
a  rupture  of  the  membrane  it  spreads  between  the  muscular  and  fascial 
planes,  and  may  eventually  discharge  on  the  surface  of  the  limb.  Septic 
involvement  of  a  neighboring  joint  may  rarely  occur,  giving  rise  to 
pyarthrosis,  which  is  not  infrequently  overlooked.  This  occurs  more 
often  in  adults  and  when  the  offending  organisms  belong  to  the  strepto- 
coccus group.  In  severer  cases,  unless  relieved  by  prompt  surgical 
intervention,  the  area  of  necrosis  extends  rapidly,  and  may  involve 
a  large  portion  or  even  the  entire  diaphysis  of  the  bone. 

In  these  cases  an  acute  hyperemia  occurs  above  and  below  the 
necrosed  area,  which  eventually  results  in  a  softening  and  lique- 
faction of  the  tissues  at  the  junction  of  the  dead  and  living  bone. 
The  periosteum  becomes  congested  and  produces  an  abundant  exudate, 
which,  later,  becomes  calcified  and  forms  a  cylindric  bridge  between 
the  proximal  and  distal  healthy  portions  of  the  bone.  This  bony 
case  or  involucrum  encloses  the  necrosed  portion  of  the  shaft,  or 
sequestrum,  which  sooner  or  later  becomes  loosened  and  lies  free  within 
its  bony  envelope.  The  involucrum  is  perforated  at  one  or  more  points 
allowing  the  escape  of  the  pus  which  is  always  present  within  its  cavity. 

In  the  very  acute  cases  septic  thrombi  form  in  the  veins  situated 
within  the  bone  and  in  the  surrounding  soft  tissues.  These  may  soften, 
and  small  portions  may  be  carried  by  the  general  circulation  to  distant 
parts  of  the  body,  giving  rise  to  metastatic  accidents. 

In  extensive  osteomyelitis  of  the  larger  bones,  the  resulting  toxemia 
may  be  so  great  as  to  cause  death  in  two  or  three  days.  Another 
type  which  is  rapidly  fatal  is  that  which  occurs  in  cases  of  virulent 
streptococcus  septicemia.  In  these  cases  the  bone  foci  may  be  small, 
often  multiple,  and  not  infrequently  are  the  only  discernible  lesions 
present. 

Symptoms. — In  the  so-called  idiopathic  cases  the  symptoms  at  first 
are  simply  those  of  a  severe  infectious  disease;  chills,  fever,  and 
prostration  may  occur  without  local  pain  or  other  evidence  pointing 
to  the  seat  of  the  lesion.  In  the  most  virulent  cases  the  temperature 
may  rise  to  105°  or  106°  F.,  and  the  toxemia  may  be  so  rapid  and 
profound  as  to  cause  delirium  and  stupor  before  the  patient  experiences 
pain  or  is  able  to  indicate  its  location.  In  these  cases  ulcerative  endo- 
carditis and  a  general  petechial  eruption  are  frequently  found  at  an 
early  period,  and  point  to  a  rapidly  fatal  termination.  In  the  less 
virulent  cases  pain  is  an  early  symptom,  and  varies  in  severity  from  a 
dull  aching  sensation  to  the  most  acute  suffering.  With  the  pain 
there  is  more  or  less  tenderness  of  the  affected  limb,  easily  appre- 


PLATE   XXII 


£ 


r. 


i 


Acute  Osteomyelitis  of  Tibia. 

Colored    photograph   of  a   fresh   specimen   removed   from   a    child 
six   years  of  aye.      (Lumiere  process.) 


INFLAMMATION  OF  BONE  743 

elated  by  pressure  over  the  bone,  or  by  forcibly  striking  the  sole  or 
palm  of  the  extremity  in  an  extended  position.  Edema  and  a  slight 
lividity  of  the  skin  are  noticeable  in  some  cases.  Edema  of  the  peri- 
osteum, seen  on  exploratory  incision,  is  one  of  the  most  reliable  signs 

of  bone  infect  inn.  In  the  later  stages  deep-seated  or  superficial  fluc- 
tuation may  be  made  out,  and  a  palpable  thickening  of  the  shaft  of 
the  bone  is  present.  In  all  acute  cases,  except  the  extremely  virulent, 
a  marked  leukocytosis  is  present.  In  the  severest  intoxications,  how- 
ever, occurring  in  individuals  with  greatly  diminished  vital  resistance, 
leukocytosis  may  be  absent.  When  the  disease  follows  a  compound 
fracture,  amputation,  or  other  bone  lesion,  the  local  symptoms  are 
generally  the  first  to  excite  the  suspicion  of  the  surgeon.  In  these 
cases  there  are  evidences  of  wound-infection,  deep-seated  pain  over 
the  affected  bone,  and  general  toxemia.  The  degree  of  the  latter  is 
rarely  as  severe  as  in  the  non-traumatic  cases  for  the  reason  that  the 
products  of  inflammation  find  an  exit,  though  often  an  imperfect  one, 
through  the  open  extremity  of  the  medullary  canal. 

Treatment. — The  treatment  of  osteomyelitis  depends  upon  the  stage 
of  the  disease,  the  virulence  of  the  infection,  the  bone  or  bones  involved, 
and  upon  the  age  of  the  individual. 

The  acute  stage  of  necrosis  and  general  toxemia,  and  those  cases  of 
acute  bacteriemia  with  a  bone  focus  or  foci,  demand,  as  any  other 
acute  suppuration,  thorough  drainage,  which  is  accomplished  by 
incising  the  soft  parts  and  the  periosteum  and  removal  of  the  bony 
cortex  with  chisel,  gouge,  and  mallet,  until  the  healthy  marrow  is 
exposed  at  either  end  of  the  incision. 

In  as  much  as  the  marrow  spaces  communicate  throughout  it  is 
undesirable  to  curet  the  medullary  cavity,  since  the  endosteum  upon 
which  the  inner  cortex  of  the  bone  depends  for  growth,  just  as  the  outer 
cortex  depends  upon  the  periosteum,  is  destroyed  by  the  procedure. 

The  endosteum  is  already  destroyed  in  places  by  the  suppuration 
and  its  vitality  lowered  by  the  infection.  Curetting  its  surface  only 
destroys  it  further,  and  opens  up  new  avenues  into  which  the  infection 
spreads. 

The  infected  area  having  been  thoroughly  exposed,  proper  drainage 
should  be  instituted  depending  upon  the  site  of  the  infection.  This 
is  best  accomplished  by  rubber  flam,  rubber  tubes,  or  gauze  and  the 
application  of  sterile  dressings  moistened  in  a  weak,  warm,  antiseptic 
solution. 

The  infection  usually  extends  close  to  the  epiphysis,  which  may 
rarely  be  involved  in  the  suppurating  process.  Should  it  become 
involved,  the  adjacent  joint  is  apt  also  to  become  infected.  The 
adjacent  joint,  however,  may,  in  the  early  stage,  contain  fluid  which 
subsides  spontaneously  after  the  primary  focus  has  been  properly 
drained.  If  the  epiphysis  and  joint  become  involved,  the  operative 
procedure  must  be  extended  to  them,  removing  a  portion  of  the 
epiphysis  and  instituting  proper  drainage  of  the  joint  by  arthrotomy. 


744  DISEASES  OF  BONE 

Great  care  must  be  taken  in  all  cases  not  to  injure  the  epiphysis 
where  it  is  not  involved  in  the  suppurative  process.  This  is  especially 
true  in  the  region  of  the  knee,  where  the  greatest  growth  occurs  from 
the  lower  epiphysis  of  the  femur  and  the  upper  epiphysis  of  the  tibia. 
The  upper  diaphyseal  part  of  the  tibia  and  the  lower  diaphyseal 
portion  of  the  femur  are  both  extremely  common  sites  of  acute  septic 
osteomyelitis. 

In  the  early  acute  stage  with  the  above  treatment,  occasionally  one 
is  fortunate  enough  to  have  the  bone  granulate  up  from  the  bottom 
and  healing  take  place.  This,  however,  is  the  exception,  as  seeondary 
operations  for  removal  of  sequestra  are  generally  necessary. 

The  healing  varies  considerably  with  the  age  of  the  patient,  and  the 
bone  involved.  In  young  children  with  growing  bones,  the  process 
of  repair  and  healing  usually  takes  place.  Even  in  children,  the 
femur,  possibly  due  to  the  difficulty  of  thorough  drainage,  does  not 
repair  so  kindly  as  do  many  of  the  other  bones.  In  adults,  due  to 
its  dense  cortex  with  its  poor  blood  supply,  and  the  injury  to  end- 
osteum  by  the  suppurative  process,  secondary  operations  for  removal 
of  sequestra  and  the  institution  of  drainage  are  usually,  indeed  almost 
always,  required,  as  the  process  usually  passes  into  a  chronic  sup- 
purating condition  requiring  repeated  operations  extending  over 
years.  This  is  one  of  the  most  difficult  conditions  in  surgery  in  which 
to  effect  a  cure,  as  it  may  recur  in  our  experience  after  remaining 
latent  for  a  period  of  twenty  years. 

There  is  another  phase  quite  rare,  and  even  more  acute  than  the 
stage  above  described,  which  is  usually  fatal.  That  is  those  cases  in 
which  there  is  an  acute  streptococcus  infection  of  the  blood  with  bone 
foci,  as  mere  incidents.  Manifestly,  here  the  primary  condition  is  the 
bacteriemia.  The  same  organism  can  be  recovered  from  the  blood 
and  the  bone  focus  upon  culture,  and  is  in  our  experience  usually  a 
streptococcus.  Drainage  of  the  bone  focus,  general  supportive  treat- 
ment, and  vaccines,  offer  the  most  hope. 

Passing  from  the  acute  stage  where  drainage  has  been  established 
by  operation  or  spontaneously,  when  the  general  condition  of  the 
patient  has  improved  and  the  periosteum  begun  to  thicken  prepara- 
tory to  the  formation  of  an  involucrum,  other  methods  of  treatment 
are  available,  depending  upon  the  extent  of  bone  necrosis  and  the 
thickening  and  calcification  of  the  periosteum. 

When  the  sequestra  are  small,  a  spicule  or  thin  plate  involving  only  a 
portion  of  the  thickness  of  the  cortex,  they  may  be  lifted  from  their 
bed  by  the  granulations,  and  the  removal  of  them  is  all  that  is  neces- 
sary, provided  the  repair  is  sufficient  to  obliterate  the  cavity.  The 
filling  of  the  cavity  with  the  Moset ig-Moorhof  mixture,  though  it  is 
more  useful  in  the  more  chronic  conditions,  will  here  greatly  aid  the 
reparative  process. 

More  frequently,  however,  the  sequestrum  is  composed  of  the 
entire  thickness  of  the  cortex  for  some  distance,  or  throughout  its 


I\'FLAMU.\TI<)\   OF   lldXE  745 

entire  length.  During  the  early  stage  of  this  condition  while  the  perios- 
teum, though  thickened,  is  still  pliable  and  plastic,  the  subperiosteal 
resection  (Nichols)  is  the  method  of  choice  where  the  hone  involved 

i-  supported  by  a  parallel  bone  as  in  the  leg  and  forearm. 

The  time  for  the  operation  varies  in  different  individual-,  depending 
upon  the  rapidity  of  the  periosteal  repair.  The  .r-ray  shadow,  and 
the  puncturing  of  the  involucrum  with  a  needle  to  ascertain  its  thick- 
ness, as  suggested  by  Nichols,  will  greatly  aid  in  determining  the  time — 
usually  from  five  to  eight  weeks  from  the  onset  of  the  disease.  The 
extent  of  the  operation  depends  upon  the  length  of  the  shaft  involved; 
the  whole  diaphysis  may  be  necrotic  and  require  removal  from  epi- 
physis to  epiphysis  or  a  portion  only  may  require  removal. 

Upon  incising  the  soft  parts  and  the  periosteum,  the  latter  is  care- 
fully stripped  from  the  shaft  with  curved  elevators  so  as  not  to  injure 
the  periosteum.  The  ease  with  which  it  strips  from  the  shaft  is  a 
practical  guide  to  the  extent  of  the  process;  as  the  limits  of  the  pro- 
cess are  reached,  the  periosteum  becomes  more  adherent.  The  diseased 
portion  of  the  shaft,  the  periosteum  having  been  separated,  is  then 
removed  with  a  Gigli  saw,  or  chisel,  and  the  edges  of  the  periosteum 
brought  together  with  interrupted  sutures  of  catgut.  If  the  whole 
shaft  is  involved,  it  usually  can  be  removed  by  grasping  it  with  strong 
forceps,  using  a  rotatory  motion  to  free  it  from  the  epiphysis. 

In  the  formation  of  the  new  bone,  since  the  growth  takes  place  from 
the  epiphyseal  ends,  and  more  particularly  from  the  epiphyseal  end  from 
which  the  bone  normally  grows  most  rapidly,  it  is  desirable  to  leave, 
if  possible,  a  portion  of  the  diaphysis,  but  it  is  not  essential  to  the 
formation  of  a  new  bone. 

The  new  formed  periosteal  shaft  is  usually  somewhat  irregular  in 
contour,  and  there  may  be  a  slight  bowing  of  the  limb  toward  the 
affected  bone  due  to  the  growth  of  the  parallel  and  unaffected  bone. 
This  new  forming  bone  fractures  easily,  but  the  fractures,  on  the  other 
hand,  repair  with  great  rapidity,  and  are  only  detected,  as  a  rule,  in 
the  course  of  a*-ray  examinations. 

The  ultimate  results  are  excellent;  as  regards  function,  there  is  usually 
but  little  if  any  shortening;  there  is  no  recurrence  of  the  suppuration 
and,  as  a  rule,  the  lesion  when  once  healed,  remains  so  (Tie?.  340, 
341,  342  and  343). 

While  the  above  operation  can  be  performed  upon  the  humerus,  it 
must  be  undertaken  at  a  later  date  when  the  involucrum  is  thicker.  It 
is  only  applicable  in  selected  cases;  it  is  much  more  liable  to  fail,  and 
if  undertaken  a  proper  appliance  should  be  used  to  overcome  the 
shortening  from  muscular  contraction.  A  bone  transplant  may  be 
inserted  or  an  intermedullary  splint  of  metal  or  ivory  may  be  intro- 
duced to  be  removed  when  the  new  periosteal  shaft  is  sufficiently 
rigid  to  withstand  the  muscular  contraction,  or  the  shortening  may  be 
overcome  by  a  properly  applied  plaster  of  Paris  splint,  orthopedic- 
appliance,  etc.  (Figs.  344  and  345). 


746 


DISEASES  OF  BONE 


In  the  late,  or  chronic  stage,  there  is  a  rigid  involucrum  enelosing 
the  sequestrum,  accompanied  by  sinuses,  and  a  foul,  purulent  <lis- 


Fig.  340 


Fig.  311 


Fig.  342 


Figs.  340,  341,  and  342. — A  case  of  acute  suppurative  osteomyelitis  of  the  tibia. 
Subperiosteal  resection  of  the  middle  two-thirds  of  the  bone.  The  three  .r-ray  plates, 
each  taken  in  two  directions,  show  regeneration  of  bone.  Fig.  340  taken  two  weeks  after 
operation.  Fig.  341  taken  one  year  and  Fig.  342,  three  years  after  operation.  Diseased 
segment  of  bone  removed  shown  in  Plate  XXII,  page  742.     (Russell.) 


INFLAMMATION  OF  BOSK 


74; 


charge.  While  the  removal  of  the  sequestrum  gives  better  drainage, 
the  cavity  dot--  not  heal,  the  discharge  continues,  and  the  condition 
remains  a  constant  source  of  danger  to  life. 


Fig.  343. — Complete  regeneration  of  tibia,  eight  months  after  a  subperitoneal  resection 
for  acute  osteomyelitis.     (Russell.) 


Fig.  344 


Fig.  345 


P'igs.  344  and  345. — Acute  osteomyelitis  of  humerus,  subperiosteal  resection  of  three- 
quarters  of  shaft.  Periosteum  already  thickened  and  partly  calcified  at  time  of  operation. 
Fig.  344.  j--ray  taken  four  weeks  after  operation.  Fig.  345.  after  eight  weeks.  Shorten- 
ing prevented  by  plaster  spica  from  waist  to  shoulder,  elbow  flexed. 

Many  methods  have  been  devised  to  obliterate  these  cavities,  and 
none  are  entirely  successful.  When  we  remember  we  are  dealing  with 
a  cavity  surrounded  by  dense  bone,  poorly  supplied  with  blood,  and 


748  DISEASES  OF  BONE 

the  seat  of  a  prolonged  infection,  the  difficulty  of  sterilization  of 
such  tissue  is  readily  understood.  In  applying  any  of  the  methods,  the 
cavity,  so  far  as  possible,  should  be  made  sterile  by  the  application  of 
carbolic  acid  followed  by  alcohol,  formalin  (1  to  50)  or  in  some  way  by 
either  heat  or  chemicals. 

Neuber  suggested  removing  the  lateral  bony  walls  and  drawing  the 
skin  and  soft  parts  over  the  cavity,  fixing  them  to.  the  bone  with 
tacks,  pins,  sutures,  etc.  Mosetig-Moorhof,  of  Vienna,  suggested,  after 
sterilizing  the  cavity  and  checking  all  bleeding,  the  introduction  of  a 
mixture  of  iodoform,  60  parts,  spermaceti,  40  parts,  and  oil  of  sesame, 
40  parts.  The  mixture  which  is  solid  at  the  body  temperature  is  heated 
and  poured  into  the  cavity,  the  soft  parts  are  then  sutured  over  it. 
The  mixture  remains  as  an  aseptic  foreign  body  with  no  further  sinus 
formation,  it  is  absorbed  bone  taking  its  place,  or  it  is  extruded  by 
the  advancing  granulations.  In  our  experience,  due  possibly  to  our 
inability  to  properly  sterilize  the  cavity,  and  check  completely  all 
oozing,  the  mixture  has  usually  been  extruded  but  has  certainly 
hastened  the  reparative  process.  The  filling  of  the  cavity,  after 
sterilizing  it  as  thoroughly  as  possible,  with  blood,  and  allowing  it  to 
clot,  and  drawing  the  tissues  over  it,  is  also  among  the  methods  which 
have  been  tried  and  met  with  some  success. 

The  introduction  of  subcutaneous  fatty  tissue  has  also  been  success- 
fully used  in  some  instances. 

If  failure  follows  these  methods,  and  secondary  and  erysipelatous 
infections  supervene,  which  frequently  occurs,  amputation  of  the 
limb  may  be  necessary  to  insure  a  complete  removal  of  the  focus. 
The  injection  of  the  sinus  with  Beck's  Paste  (bismuth  in  vaseline) 
followed  by  x-ray  pictures  will  often  enable  one  to  localize  cavities  and 
sequestra  otherwise  not  detected.  In  the  flat  bones,  as  the  bones 
of  the  skull  where  necrosis  follows  avulsion  of  the  scalp,  the  drilling 
of  numerous  holes  through  the  outer  table  allows  the  blood  supply 
to  reach  the  surface,  granulations  then  form  covering  the  outer  table 
which  can  be  skin-grafted  at  a  later  date. 

Chronic  localized  bone  abscesses  may  exist  for  a  very  long  time. 
They  may  be  small  or  involve  a  considerable  portion  of  the  bone. 
They  have  very  dense  walls,  usually  no  sequestrum  is  found,  and 
the  repair  is  apt  to  be  slow.  At  operation  the  walls  should  be  cut 
through  until  healthy  marrow  is  entered  to  insure  proper  blood  supply. 
The  cavity  may  then  be  obliterated  by  the  sterile  organized  blood 
clot,  the  Neuber  flap  method,  or  the  Mosetig-Moorhof  iodoform 
mixtures. 

Acute  Epiphysitis. — It  frequently  happens  in  infants  that  an  acute 
septic  osteomyelitis  is  limited  to  the  epiphysis  of  a  bone.  As  the 
result  is  almost  invariably  a  suppurative  arthritis,  the  disease  will 
be  considered  more  fully  in  Chapter  XXVIII. 

Subacute  and  Chronic  Osteomyelitis. — Under  this  heading  are 
included  a  number  of  affections  possessing  many  features  in  common, 


INFLAMMATION  OF  BONE  749 

but  differing  widely  in  their  etiology.  They  are  all  of  infectious  origin, 
but  the  infecting  agent  is  not  capable  of  causing  either  rapid  destruc- 
tion of  tissue  or  severe  systemic  reaction.  In  many  of  them  the  chief 
clinical  feature  of  the  disease  is  sclerosis,  which  is  due  to  an  excessive 
reparative  effort.  As  these  affections  differ  considerably  in  their 
general  behavior,  clinical  history,  and  treatment,  each  will  be  con- 
sidered separately. 

Subacute  Cortical  Osteomyelitis  of  Septic  Origin,  also  spoken  of  as 
suppurative  periostitis.  This  is  an  inflammatory  process  limited  to 
the  periosteum  and  cortical  layer  of  the  bone,  resulting  in  suppuration 
and  necrosis,  the  latter  being  limited  to  a  thin  superficial  plate  of  com- 
pact tissue  which  separates  slowly  by  the  processes  already  described. 
It  occurs  by  preference  in  the  skull,  ribs  or  sternum. 

The  symptoms  are  localized  pain  and  tenderness,  the  occurrence  of 
an  oval  fluctuating  swelling,  with  edema  and  redness  of  the  skin,  if 
the  disease  is  located  in  a  superficial  portion  of  the  bone. 

The  treatment  is  by  free  incision,  evacuation  of  the  pus,  and  removal 
of  the  necrosed  area. 

Osteomyelitis  Albuminosa. — A  non-suppurating  infection  of  bone, 
characterized  by  great  thickening  of  the  periosteum,  which  when 
incised  is  found  to  be  due  to  the  presence  of  a  thick,  gelatinous 
material.  Dor  claims  to  have  isolated  a  micro-organism,  with  which 
he  reproduced  the  symptoms  in  animals.    The  disease  is  rare. 

The  treatment  consists  in  incision  of  the  periosteum  and  removal 
of  the  galatinous  mass. 

Typhoid  Osteomyelitis  is  a  fairly  frequent  sequel  of  typhoid  fever. 
It  occurs  as  a  small  circumscribed  bone  infection  which  slowly  causes 
necrosis  of  the  cortex  with  discharge  of  infected  material  beneath  the 
periosteum.  This  eventually  gives  rise  to  an  abundant  formation  of 
granulation  tissue  between  the  bone  and  periosteum,  and  occasion- 
ally rupture  of  that  membrane  and  infiltration  of  the  soft  parts.  In 
mixed  infections  suppuration  may  be  present. 

The  symptoms  of  the  disease  are  localized  pain,  often  of  a  severe 
type,  over  a  small  area  of  bone.  This  continues,  and  is  accompanied 
by  tenderness  and  thickening  of  the  periosteum,  but  with  little  or 
no  fever.  When  the  bone  focus  ruptures,  the  pain  is  relieved,  and  a 
soft  subperiosteal  swelling  occurs,  which  is  elastic  and  often  gives 
the  sensation  of  fluctuation.  The  tibia,  ribs,  ulna,  and  small  bones 
of  the  hands  and  feet  are  the  ones  most  frequently  affected. 

The  treatment  should  be  incision  and  drainage,  with  curettage  and 
packing  of  the  bony  cavity.  In  the  early  painful  stage,  the  bone 
cavity  should  be  opened  if  it  can  be  accurately  located. 

Syphilis  of  Bone. — The  syphilitic  lesions  of  bone  occur  both  in  the 
early  and  late  stages  of  the  disease.  In  the  early  stage  they  are,  as 
a  rule,  painful  but  not  destructive;  in  the  late  stage  they  are  more 
destructive,  but  not,  as  a  rule,  as  painful  as  the  septic  bone  diseases. 
In  the  early  period  the  disease  is  frequently  limited  to  the  periosteum, 


750  DISEASES  OF  BONE 

and  consists  in  hyperemia  and  a  moderate  exudate,  both  of  which 
disappear  under  appropriate  treatment;  in  the  latter  period  the 
lesions  are  gummatous  in  character,  and  are  followed  by  necrosis  and 
its  sequela3,  by  sclerosis  of  the  bone,  and  by  thickening  of  the  perios- 
teum. When  the  gummatous  process  occurs  in  the  shaft  of  a  long  bone, 
the  focus  is  not,  as  a  rule,  surrounded  by  a  dense  layer  of  compact  bone, 
as  in  septic  osteomyelitis,  and  for  this  reason  often  it  is  difficult  to 
accurately  determine  the  limits  of  the  disease.  Several  such  gum- 
matous areas  may  occur  in  a  single  bone. 

When  the  process  occurs  in  an  epiphysis  it  occasionally  perforates 
the  articular  cartilage  and  gives  rise  to  a  chronic  arthritis,  which 
closely  resembles  the  tuberculous  variety. 

In  rare  instances  syphilis  seems  to  occasion  only  hyperplasia  with- 
out previous  gummatous  formation.  In  these  cases  the  bone  is  appar- 
ently greatly  thickened,  either  from  new-formed,  hard  osseous  tissues, 
or  from  a  dense  fibrous  thickening  of  the  periosteum. 

It  will  thus  be  seen  that  the  tertiary  lesions  of  syphilis  in  the  bones 
consist  in  irregular  areas  of  gummatous  softening,  irregular  areas 
of  sclerosis,  and  thickening  of  the  periosteum.  Martin  Ware  has 
recently  called  attention  to  these  characteristic  features  as  revealed 
by  radiograms  of  the  long  bones,  and  states  that  the  diagnosis  often 
can  be  established  by  radiography  without  additional  data. 

Symptoms. — The  symptoms  of  the  early  bone  lesions  of  syphilis 
are  pain  occurring  at  night  in  one  or  more  bones,  tenderness,  and 
occasionally  periosteal  thickening.  The  symptoms  of  the  later  mani- 
festations are  either  those  of  localized  periosteal  gummata,  which 
may  break  down  and  cause  caries  or  necrosis  of  the  underlying  bone, 
those  of  the  subacute  cortical  variety  of  osteomyelitis,  or  those  of 
a  localized  or  diffuse  osteomyelitis  beginning  in  the  interior  of  the  bone. 
The  syphilitic  forms  of  osteomyelitis  are  to  be  distinguished  from  those 
due  to  septic  infection  by  the  absence  of  fever,  by  the  absence  of 
marked  pain,  and  the  presence  of  sclerosis.  Gummata  occurring  in 
the  interior  of  a  long  bone  may  rarely  give  rise  to  the  same  expansion 
of  the  cortex  as  is  seen  in  central  sarcoma. 

In  addition  to  the  conditions  just  described,  syphilitic  osteochondritis 
is  frequently  seen  in  the  hereditary  form  of  the  disease.  This  condi- 
tion is  characterized  by  an  overgrowth  of  the  epiphyseal  cartilage 
and  adjacent  portions  of  the  shaft  of  the  long  bones.  When  the 
disease  occurs  in  the  metacarpal  bones  or  phalanges  the  condition 
is  spoken  of  as  a  dactylitis  syphilitica,  which  closely  resembles  the  tuber- 
culous variety.  The  disease  may  remain  stationary,  or  break  down 
and  give  rise  to  necrosis,  separation  of  the  epiphysis,  or  destruction  of 
the  joint. 

Treatment. — In  all  syphilitic  bone  lesions,  salvarsan  and  internal 
treatment  should  be  administered  until  the  physiologic  effect  is  ap- 
parent: mercury  in  the  secondary  stage;  mercury  and  potassium 
iodide  for  the  late  lesions.     If  a  periosteal  gummatous  abscess  results, 


INFLAMMATION  OF  HONE  751 

it  should  be  freely  opened  and  any  cortical  necrosis  removed  by  the 
chisel  and  mallet.  In  central  syphilitic  osteomyelitis  with  necrosis, 
the  treatment  should  be  the  same  as  in  the  septic  form  described  on 
page  743. 

Tuberculosis  of  Bone. — Tuberculosis  affects  by  preference  the 
epiphyses  of  the  long  bones;  it  occurs  also  in  the  shafts  of  the  meta- 
carpals, metatarsals,  and  phalanges  {spina  ventosa);  and  in  the  short 
and  flat  bones.  It  rarely  occurs  in  the  diaphyses  of  the  long  bones, 
although  Vignard  and  Mouriquand  have  recently  reported  its  oc- 
currence in  the  humerus,  radius,  clavicle,  and  fibula,  and  Stiles  states 
that  in  Scotland  numerous  examples  of  a  tuberculous  osteomyelitis 
of  the  long  bones  particularly  the  tibia  are  observed. 

Miliary  tubercles  form  first  in  the  marrow,  and  by  their  coalescence 
a  more  or  less  extensive  destruction  of  tissue  occurs,  resulting  in  a 
circumscribed  tuberculous  bone  abscess  or  the  formation  of  a  tuberculous 
sequestrum. 

In  tuberculous  osteomyelitis  of  the  articular  extremity  of  a  long 
bone  the  process  may  begin  just  beneath  the  cartilage  or  on  the  shaft 
side  of  the  epiphysis. 

In  either  event  the  disease  may  spread  and  involve  the  joint,  or  may 
remain  limited  to  the  extremity  of  the  bone.  In  the  latter  event  a 
localized  tuberculous  bone  abscess  may  result,  surrounded  by  an  area 
of  sclerosis.  The  joint-sequelae  of  tuberculous  epiphysitis  will  be 
considered  in  Chapter  XXVIII. 

Symptoms. — The  symptoms  of  tuberculous  osteomyelitis  are  mod- 
erate deep-seated  pain  in  the  limb,  tenderness,  and  a  thickening  of 
the  bone.  If  the  disease  invades  the  soft  parts,  abscesses  may  form, 
which  rupture  on  the  skin  and  give  rise  to  characteristic  tuberculous 
fistula?,  described  on  page  232.  In  many  cases  the  focus  of  infection 
is  small,  but  the  resulting  sclerosis  of  bone  is  marked.  The  disease 
is  prone  to  affect  the  vertebrae  and  the  small  bones  of  the  hand  and 
foot.  Tuberculous  dactylitis  is  a  name  given  to  a  tuberculous  osteo- 
myelitis of  the  shaft  of  one  of  the  metacarpas,  metatarsals,  or  phalanges. 
The  chief  characteristics  of  tuberculous  osteomyelitis  are  the  chronicity 
of  the  process,  the  absence  of  severe  pain,  leukocytosis,  and  evidences 
of  general  sepsis.  In  many  cases  the  pain  and  tenderness  are  not 
sufficiently  circumscribed  accurately  to  locate  the  lesion.  In  these 
instances  an  x-ray  examination  will  be  found  of  great  advantage 
(Fig.  346). 

Treatment. — In  the  early  stages  the  treatment  of  tuberculous  bone 
disease  should  be  conservative,  and  consists  in  rest,  counter-irritation, 
tonics,  and  hygienic  measures.  Elastic  constriction  of  the  limb 
above  the  seat  of  disease  by  means  of  a  rubber  band,  as  recommended 
by  Bier,  seems  to  exert  a  favorable  influence.  If,  however,  the  dis- 
ease is  progressive  in  spite  of  these  measures,  it  should  be  attacked 
surgically. 

The  treatment  of  the  cortical  form  of  tuberculous  osteomyelitis, 


752 


DISEASES  OF  BONE 


which  occurs  chiefly  in  the  flat  bones,  is  by  incision  and  scraping  away 
the  carious  bone,  followed  by  the  application  of  pure  carbolic  acid 
and  packing  with  iodoform  gauze.  In  the  central  variety  the  bone 
should  be  freely  opened  and  the  cheesy  focus  found  and  curetted.  If 
a  sequestrum  is  present,  it  should  be  removed  and  the  cavity  disin- 
fected and  packed.  In  the  acute  diffuse  form  of  the  disease  ampu- 
tation may  be  necessary. 


Fig.  346. — Spina  ventosa  or  tuberculous  dactylitis  (x-ray). 


Actinomycosis  of  Bone. — Infection  of  bone  by  the  ray  fungus 
occasionally  occurs.  The  lower  jaw  is  the  bone  usually  affected,  and 
the  infection  is  generally  supposed  to  take  place  through  a  carious 
tooth.  The  result  is  the  slow  development  of  an  osteomyelitis  with 
secondary  granulomatous  deposits  beneath  the  periosteum  and  in 


NUTRITIVE  DISTURBANCES  IN  BONK  753 

the  soft  tissues.  These  latter  break  down  and  give  rise  to  indolent 
fungating  ulcers  and  sinuses  which  discharge  a  watery  pus  containing 
numerous  granules  of  a  lemon-yellow  color. 

Treatment. — The  treatment  should,  if  possible,  consist  in  removal 
of  the  diseased  area  and  the  internal  exhibition  of  potassium  iodide 
or  the  salts  of  copper. 

Sequelae  of  Bone  Inflammation. — These  are  necrosis,  caries,  and 
hyperplasia  of  the  bone  or  periosteum. 

Necrosis  has  been  described  as  gangrene  of  the  bone,  caries  as 
ulceration.  In  the  former  the  mass  of  dead  bone  is  separated  from 
the  living  in  the  tissues  by  processes  already  described,  and  may 
remain  as  a  foreign  body;  in  the  latter  the  process  is  one  of  molecular 
death,  the  debris  of  which  is  carried  away  by  the  fluid  discharges.  In 
necrosis  the  line  of  demarcation  between  the  living  and  the  dead 
tissue  is  well  marked;  in  caries  the  bone  is  often  honey-combed  and 
the  division  between  the  living  and  the  dead  portions  indistinct.  The 
treatment  of  these  conditions  has  already  been  described. 

Sclerosis  consists  in  a  new  formation  of  osseous  tissue  within  the 
cancellous  spaces  and  Haversian  canals,  resulting  in  an  increased 
density  of  the  bone  and  often  a  marked  increase  in  its  size.  The  process 
is  a  slow  one,  and  is  due  to  the  presence  of  some  chronic  irrita- 
tion or  foreign  body,  as  a  tuberculous  or  syphilitic  focus  of  inflam- 
mation, an  area  of  necros's,  or  an  imbedded  bullet.  The  condition 
is  a  symptom  rather  than  a  disease,  as  formerly  supposed. 

In  the  treatment  of  this  condition  an  effort  should  be  made  to 
locate  the  irritating  focus  and  remove  it.  For  this  purpose  the  use  of 
the  .r-rays  is  often  of  great  service. 

Diffuse  periosteal  thickening  is  a  condition  often  associated  with 
the  non-suppurating  forms  of  osteomyelitis,  especially  those  due  to 
syphilis.  The  condition  rarely  gives  rise  to  symptoms,  and  no  treat- 
ment is  required  other  than  that  addressed  to  the  causative  disease. 


NUTRITIVE   DISTURBANCES   IN   BONE. 

The  nutritive  disturbances  of  the  bony  skeleton  form  an  inter- 
esting but  little  understood  group  of  diseases. 

The  present  classification  is  the  result  of  a  number  of  excellent 
observations  by  accurate  clinical  observers,  but  without  sufficient 
pathologic  study  to  give  us  a  comprehensive  idea  of  the  processes 
which  result  in  the  various  clinical  types  of  the  disease.  Of  late  the 
tendency  has  been  to  associate  these  disturbances  with  abnormalities 
in  the  secretions  of  one  or  more  of  the  ductless  glands. 

In  general  it  may  be  said  that  there  are  three  classes  of  cases: 

First,  those  in  which  the  chief  pathologic  condition  is  an  overgrowth 

of  bony  tissue,   with  the  various  secondary  changes  and  resulting 

deformities;    second,  those  in  which  the  chief  factor  is  an  atrophy  of 

4S 


754  DISEASES  OF  BONE 

the  bony  tissues;  and  third,  those  in  which  the  osteogenetic  process 
is  an  irregular  one. 

In  the  first  class  will  be  found  osteitis  deformans,  acromegaly, 
and  leontiasis;  in  the  second,  osteomalacia  and  osteogenesis  im- 
perfecta; while  in  the  third  we  may  include  chondrodystrophia  and 
rachitis. 

It  is  not  improbable  that  further  pathologic  study  will  result  in 
diminishing  the  number  of  individual  diseases,  as  there  is  a  notice- 


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Hi  ->  fl 

l>JH 

■  ^     ^^^ 

Ak^ v  i     i 

Fig.  347. — Osteitis  deformans  (Paget' s  disease). 

able  similarity  in  the  pathologic  changes  in  the  members  of  each  class, 
the  individual  differences  being  largely  in  the  location  of  the  lesions 
and  the  age  at  which  thev  appear. 

Osteitis  Deformans — Osteitis  deformans,  first  described  by  Paget, 
is  a  disease  of  adult  life,  characterized  by  a  slow  and  painful  enlarge- 
ment of  certain  bones  of  the  body.  The  changes  in  the  bones  con- 
sist in  atrophy  of  the  cancellous  tissue,  resulting  in  the  formation  of 
large  medullary  spaces  and  canals,  with  more  or  less  softening  and  later 
hyperplasia  of  the  compact  tissue,  increasing  to  a  considerable  degree 


NUTRITIVE  DISTURBANCES  IN  BONE  755 

the  size  of  the  bone.  The  disease  attacks  by  preference  the  long 
bones  of  the  skeleton,  which  may  become  curved  by  the  weight  of  the 
body;  also  the  cranial  bone",  the  spine,  and  pelvis.  Great  thickening 
of  the  skull,  curvature  of  the  spine,  and  bow-legs  are  the  chief  deform- 
ities. The  disease  is  progressive  and  is  more  frequent  in  men.  Frac- 
tures of  the  affected  bones  occur  from  apparently  trivial  traumata. 
While  little  is  known  regarding  its  etiology,  it  is  almost  always  asso- 
ciated with  an  advanced  degree  of  arterial  sclerosis  (Fig.  347). 

Symptoms. — The  symptoms  are  early  pain  and  discomfort  in  the 
affected  bones;  later,  deformity  and  a  characteristic  attitude  and 
gait.  The  head  is  bowed  forward,  the  spine  curved,  the  shoulders 
high,  and  the  knees  widely  separated.  The  patient  walks  with  a  slow, 
waddling  gait. 

Treatment. — The  treatment,  up  to  the  present  time,  has  been  abso- 
lutely unsatisfactory.     Only  hygienic  measures  are  to  be  recommended. 

Acromegaly. — Acromegaly  is  a  chronic  disease  of  the  skeleton,  char- 
acterized by  progressive  enlargement  of  the  bones  of  the  hands  and 
feet,  of  the  face,  and  often  those  of  the  trunk  and  extremities.  The 
disease  is  now  generally  regarded  as  being  due  to  hyperpituitarism,  as 
it  is  often  associated  with  new  growth  or  other  gross  change  in  the 
hypophysis. 

Symptoms. — The  symptoms  begin,  as  a  rule,  in  early  adult  life,  and 
consist  in  deformities  of  the  affected  regions.  The  hands  and  feet 
enlarge,  the  under  jaw  becomes  prominent,  the  nose  and  lips  become 
thickened,  and  the  eyebrows  massive.  The  voice  becomes  coarse  and 
deep  in  pitch.  Later,  a  certain  amount  of  mental  sluggishness  is 
apparent  and  the  sexual  function  may  be  impaired.  In  some  cases 
headaches  are  a  prominent  symptom,  and  glycosuria  often  is  present. 
When  due  to  a  neoplasm  of  the  hypophysis  a  bitemporal  hemianopsia 
frequently  develops,  with  other  general  symptoms  of  brain  tumor. 
The  prognosis  is  grave,  but  in  many  instances  the  progress  is  slow, 
and  the  duration  of  life  may  not  be  shortened. 

Treatment. — The  treatment  in  the  past  has  been  unsatisfactory. 
Gushing  has  recently  advocated  operative  treatment,  with  a  view 
to  exposing  the  gland,  removing  a  part  of  the  tumor  or  effecting 
decompression  by  extensive  removal  of  the  anterior  wall  of  the  sella 
turcica.  Recently  he  exhibited  to  the  Society  of  Clinical  Surgery  a 
patient  upon  whom  he  had  thus  operated,  with  marked  relief  of 
symptoms. 

Leontiasis. — -Leontiasis  is  a  progressive  hypertrophy  of  the  bones 
of  the  upper  part  of  the  face,  giving  rise  to  a  peculiar  lion-like  counte- 
nance. The  bone  changes  are  similar  to  those  of  the  preceding  condi- 
tions and,  in  their  development,  often  encroach  upon  the  orbits, 
accessory  nasal  cavities,  and  foramina.  In  the  latter  situation,  pressure 
upon  sensory  nerve  trunks  may  give  rise  to  neuralgic  pains. 

Treatment. — The  treatment  of  leontiasis  is  undeveloped.  The 
writer  has,  on  two  occasions,  exposed  and  removed  hypertrophied 


756  DISEASES  OF  BONE 

areas  which  were  causing  noticeable  deformity.  The  appearance  was 
temporarily  improved,  but  the  disease  continued  to  progress. 

Osteomalacia. — Osteomalacia  is  a  rarefying  degeneration  of  the 
bones  of  the  skeleton,  resulting  in  enlargement  of  the  medullary  spaces, 
replacement  of  the  calcareous  elements  by  a  highly  vascular  fibro- 
cellular  tissue,  and  a  thinning  of  the  cortex.  This  results  in  softening, 
deformity,  and  a  tendency  to  fracture  on  the  slightest  provocation. 
Little  is  known  of  its  etiology,  except  that  it  is  apt  to  follow  multiple 
pregnancies  in  rapid  succession.  This  has  given  rise  to  the  theory  that 
it  may  be  due  to  an  excess  or  a  diminution  of  an  internal  secretion 
possibly  that  of  one  of  the  sexual  organs,  or,  as  suggested  by  Bossi,  of 
the  suprarenal  gland. 

The  early  symptoms  of  the  disease  are  pain  in  the  affected  bones, 
generally  the  pelvis,  weakness,  and  a  peculiar  characteristic  attitude 
and  gait.  The  patient  will  bend  forward  and  walk  slowly  with  short 
steps,  often  supporting  the  body  by  leaning  with  the  hands  upon 
nearby  objects. 

The  treatment  should  consist  in  the  cessation  of  lactation,  the  admin- 
istration of  phosphates,  cod-liver  oil,  and  iron,  with  sea-bathing  and 
other  hygienic  measures.  Bossi  and  Rebaudi  report  a  cure  by  the 
hypodermic  injection  of  adrenalin. 

Osteogenesis  Imperfecta. — A  congenital  condition  similar  to  osteo- 
malacia, resulting  in  atrophy  of  the  bony  cortex  and  extreme  fragility 
of  the  bones. 

The  children,  as  a  rule,  are  undersized  at  birth,  may  be  deformed 
(short  legs),  and  are  often  mentally  deficient.  Fractures  occur  on  the 
slightest  violence;  not  infrequently  one  or  more  bones  are  broken 
at  the  time  of  birth.  There  is  no  satisfactory  treatment  for  this 
condition. 

Chondrodystrophia. — Sometimes  called  congenital  rickets.  A  rare 
condition  of  malnutrition  during  intra-uterine  life,  resulting  in  an 
arrest  of  development  of  the  long  bones,  particularly  those  of  the  lower 
extremities.  Most  of  these  children  are  stillborn.  When  they  survive 
they  are  dwarfed,  with  bow-legs,  short,  curved  arms,  and  sunken 
noses.  They  generally  exhibit  also  a  peculiar  deformity  of  the  hands, 
called  by  the  French  main-en-trident,  in  which  the  entire  hand  is  short- 
ened and  the  fingers  all  about  the  same  length.  The  spine  is  frequently 
curved,  the  abdomen  prominent,  giving  the  deformity  described  as 
spondylolisthesis. 

Rachitis. — Rachitis  is  a  constitutional  disease,  which  may  rarely 
be  congenital,  but  is  generally  due  to  defective  nutrition  during 
infancy,  resulting  in  delayed  calcification  of  the  bones,  faulty  epiphy- 
seal growth,  and  various  deformities  of  the  skeleton.  Frichsen  has 
described  the  condition  as  follows:  "The  essential  features  of  the 
process  are,  first,  an  exaggeration  of  the  processes  immediately  pre- 
paratory to  the  development  of  new  bone;  secondly,  an  imperfect 
conversion  of  the  preparatory  tissue  into  true  bone;    and  thirdly,  a 


NUTRITIVE  DISTURBANCES  IN  BONE 


757 


great  irregularity  of  the  whole  process."  There  are  thickening  and 
deformity  of  the  epiphyseal  cartilages,  thickening  and  hyperemia  of 
the  periosteum,  enlargement  of  the  medullary  spaces,  and  a  condition 
of  sponginess  and  hyperemia  of  the  cortex. 

Symptoms. — The  early  symptoms  of  rachitis  are  digestive  disturb- 
ances, flatulence,  diarrhea  or  constipation,  sweating  about  the  head 
when  asleep,  delayed  dentition,  delayed  closure  of  the  fontanelles,  and 
delayed   walking.     The  deformities  consist  of  enlargements  at  the 


Fig.  348. — Rachitic  deformity  of  the  legs. 


epiphyseal  junctions,  chiefly  observed  on  the  thorax  at  the  points  of 
union  of  the  ribs  and  costal  cartilages  (rachitic  rosary),  at  the  lower 
extremity  of  the  tibia,  and  lower  extremity  of  the  radius;  irregulari- 
ties in  the  outline  of  the  skull,  which  may  be  shortened  anteroposte- 
riorly  or  elongated;  the  forehead  is  often  flat,  high,  and  square,  with 
or  without  supra-orbital  bosses;  the  thorax  and  pelvis  are  deformed; 
there  is  curvature  of  the  long  bones,  especially  of  the  lower  extremity, 
which  is  generally  the  result  of  bending  from  too  early  attempts  at 
walking,  or  from  faulty  postures  or  muscular  traction.     There  are 


758 


DISEASES  OF  BONE 


enlargement  of  the  abdomen,  and  a  bulging  of  the  lower  ribs,  giving 
rise  to  an  apparent  constriction  opposite  the  attachment  of  the  dia- 
phragm (Harrison's  sulcus).  Rachitic  children  who  walk  frequently 
suffer  from  anteroposterior  or  lateral  curature  of  the  spine,  from  bow- 
leg, knock-knee,  and  Hat  foot  (Fig.  348). 

Treatment. — The  treatment  of  rachitis  in  the  early  stage  should  be 
to  give  the  best  possible  diet,  which  should  always  include  orange- 
juice  and  meat  broths;  to  administer  iron,  cod-liver  oil,  and  phos- 
phorus; to  give  daily  salt  baths  and  general  massage;  and  to  keep 
the  child  as  much  as  possible  in  the  open  air  and  sunshine.  Efforts 
at  walking  should  be  discouraged  until  the  nutritive  disturbances 
have  been  corrected.    In  the  early  stage  of  bony  deformity,  when  the 

bones  are  soft  and  yielding,  much  may 
be  accomplished  by  manipulation,  braces, 
and  plaster  casts,  especially  in  deformities 
of  the  extremities.  At  a  later  period  os- 
teotomy or  osteoclasis  may  be  necessary. 


Cartilage. 


Cartilage. 


TUMORS    OF   BONE. 


Osteoma. — Osteomata,  or  bony  tum- 
ors, are,  as  a  rule,  either  calcified  chondro- 
mata  or  bony  outgrowths  at  points  of 
attachments  of  muscles;  the  former  occur 
in  the  long  bones  at  or  near  the  epiphy- 
seal lines  or   in    the    flat  bones  in  the 
neighborhood    of    cartilaginous    tracts, 
and   are  generally  connected  with  the 
bone  by  a  plate  of  cartilage;   the  latter 
are  frequently  found  arising  from  the 
adductor  tubercle  of  the  femur  or  from 
other  points  of   muscular   attachment, 
are  often  surrounded  by  a  cartilaginous 
capsule,   and   are  occasionally   covered 
by  bursse. 
Osteomata  are  slowly  growing  tumors,  which,  however,  may  reach 
an  enormous  size.    They  are  innocent  in  character,  and  only  produce 
pain  and  other  disturbances  by  pressure  on   neighboring  structures 
(Fig.  350). 

Chondroma. — Chondromata,  or  cartilaginous  tumors,  are  frequently 
encountered  growing  from  the  long  bones,  generally  from  the  neigh- 
borhood of  an  epiphyseal  line.  They  are  encapsulated,  and  often 
occupy  hollowed-out  spaces  in  the  bone.  These  tumors  are  most 
frequently  seen  growing  from  the  small  bones  of  the  hand,  and  are 
commonly  multiple  (Fig.  351).  They  may  reach  a  large  size  and 
cause  much  discomfort.  They  are  always  innocent,  but  should  be 
removed  if  they  produce  inconvenience.     Chondromata  may  rarely 


Fig.  349. — Exostosis  of  adduc- 
tor tubercle  of  femur:  its  surface 
was  clad  with  cartilage  and  sur- 
mounted by  a  bursa.     (Orlow.) 


TUMORS  OF  BONE 


759 


develop  in  the  interior  of  the  large  bones  in  the  majority  of  instances 
at  or  near  the  epiphyseal  line.    Here  they  may  expand  the  cortex  and 


Fig.  350. — Radiograph  of  exostosis  of  shaft  of  femur. 


Fk;.  351. — Chondroma  of  hand. 


760  DISEASES  OF  BONE 

give  rise  to  symptoms  and  signs  closely  resembling  medullary  sarcoma 
(Fig.  354).  Myxomatous  degeneration  may  occur  and  give  rise  to  a 
bone  cyst. 

Fibroma  and  Lipoma. — Fibromata  and  lipomata  are  occasionally 
found  growing  from  the  periosteum,  but  differ  in  no  respect  from  similar 
growths  in  other  tissues. 

Bone  Cysts. — The  majority  of  bone  cysts  occur  in  connection  with 
that  condition  described  as  ostitis  fibrosa.  In  this  condition,  which 
is  thought  by  some  to  be  due  to  a  chronic  infective  process,  the  medulla 
of  the  bone  is  partly  replaced  by  fibrous  tissue.  This  may  expand  the 
bone  in  places  and  result  in  an  atrophy  of  the  cortex.  Later  degen- 
erative changes  result  in  the  formation  of  single  or  multiple  cysts. 
These  cysts  are  of  fairly  frequent  occurrence  in  certain  long  bones,  and 
when  they  reach  a  sufficient  size  to  be  recognized  clinically,  they 
may  or  may  not  present  a  definite  fibrous  lining  membrane.  This 
membrane  may  contain  small  masses  of  cartilage  or  newly  formed 
bone,  and  in  nearly  all  cases  giant  cells.  The  fluid  is  reddish  or  brown- 
ish in  color,  but  true  blood  cysts  never  occur  in  this  condition. 

Of  the  rarer  varieties  of  bone  cysts  may  be  mentioned,  the  degen- 
erated myelomata,  and  chondromata;  the  cystic  changes  in  a  medul- 
lary round  or  mixed-cell  sarcoma  (which  not  infrequently  are  true 
blood  cysts),  the  occasional  cysts  which  result  from  a  subperiosteal 
hematoma,  the  bony  wall  being  partly  formed  by  the  surrounding 
calcified  periosteum;  and  the  cysts  rarely  found  in  Paget's  disease, 
osteomalacia,  arthritis  deformans,  and  in  the  callus  of  fractures. 
The  cysts  associated  with  ostitis  fibrosa  occur  most  commonly  in  the 
humerus,  femur  and  tibia;  cartilaginous  cysts  in  the  phalanges;  degen- 
erated myelomata  in  the  clavicle. 

Symptoms. — The  disease  is  often  preceded  by  a  history  of  trauma. 
While  pain  in  the  bone  may  be  present,  in  the  majority  of  instances 
swelling  is  the  first  manifestation  of  the  disease  noted  by  the  patient; 
spontaneous  fracture  is  frequent. 

In  cystic  disease,  the  bone  is  generally  enlarged  and  the  cortex  often 
markedly  atrophied,  giving  rise  to  the  egg-shell  sensation  on  palpa- 
tion. This,  with  the  similar  circumscribed  light  area  in  an  x-ray  plate, 
will  often  lead  to  the  diagnosis  of  a  solid  tumor  of  bone,  from  which 
the  cases  are  with  difficulty  differentiated. 

Treatment. — The  treatment  consists  in  freely  opening  the  cyst, 
curetting  all  diseased  tissue  to  normal  vascular  bone,  and  treating 
the  cavity  as  those  resulting  from  osteomyelitis.  If  the  disease  is 
proved  to  be  sarcoma,  amputation  should  be  performed  in  all  but 
the  giant-cell  variety. 

Malignant  Tumors. — All  primary  malignant  tumors  of  bone  are  of 
mesoblastic  origin ;  the  carcinomata  occur  only  as  secondary  metastatic 
deposits. 

Sarcoma. — Sarcomata  may  arise  from  the  periosteum  and  gradually 
extend  around  the  bone;  or  they  may  develop  from  the  cancellous 


TUMORS  OF  BONE 


761 


tissue  of  the  medullary  canal  and  by  their  growth  expand  the  cortical 
shell.  The  former  are  called  peripheral  or  periosteal  sarcomata;  the 
latter,  central  <>r  medullary  sarcomata. 

Periostea]   sarcomata   arc  more  frequent  in  the  diaphyses  of   the 

Long  bones,  and  by  their  growth  develop  around  the  shaft,  which 
may  be  seen  by  the  x-rays  to  present  a  fairly  normal  appearance 
in  the  centre  of  the  tumor.  Exceptionally  they  grow  from  a  limited 
portion  of    the    cortex   and  present    well-marked   oval    tumor-     Fig. 


Fig.  352. — Periosteal  sarcoma  of  tibia. 


352).  In  central  sarcomata  the  growth  distends  the  bone  often  to  an 
enormous  size,  and  the  surrounding  capsule  of  compact  tissue  may 
become  so  atrophied  as  to  give  to  the  examining  hand  the  sensation 
of  a  crackling  egg-shell.  On  .r-ray  examination  the  fusiform  dilata- 
tion of  the  cortex  can  be  readily  made  out  Fig.  353 1.  Periosteal 
sarcomata  are  most  frequently  of  the  round-cell  variety;  they  often 
follow  an  injury,  grow  rapidly,  and  are  extremely  malignant.  Less 
frequently  they  are  made  up  of  spindle  or  mixed  cells  and  are  less 


762 


DISEASES  OF  BONE 


malignant.    They  commonly  present,  in  their  interior,  bony  trabecular 
growing  at  right  angles  to  the  shaft. 

Central  sarcomata  are  most  frequently  of  the  myeloid  type.  They 
develop  commonly  in  the  ends  of  the  long  bones  or  in  the  horizontal 
ramus  of  the  mandible,  grow  slowly,  and  while  they  cause  extensive 
destruction  of  bone,  rarely  invade  the  articular  cartilage  and  never 
metastasize.  Of  late  most  surgeons  have  placed  them  in  a  separate 
class  and  designated  them  myelomata,  to  distinguish  them  from  the 
truly  malignant  round,  spindle  or  mixed-cell  varieties.    Less  frequently 


Fig.  353. — -Radiograph  of  early  central  sarcoma  of  humerus. 


the  round-cell  or  mixed  sarcomata  are  found  developing  from  the 
centre  of  the  bone;  generally,  however,  from  the  shaft. 

Sarcomata  apparently  occur  in  the  bones  most  liable  to  injury; 
thus,  of  the  long  bones,  the  femur,  tibia,  and  humerus  are  the  ones 
in  which  the  disease  is  most  frequently  encountered;  next  in  frequency 
come  the  radius,  ulna,  and  clavicle.  Of  the  other  bones,  the  superior 
and  inferior  maxilla,  the  ilium,  and  spine  are  frequently  the  seat  of 
the  disease.  In  the  long  bones  the  disease  is  generally  located  near 
an  active  epiphysis,  as  the  lower  extremity  of  the  femur  or  radius 
and  the  upper  extremity  of  the  tibia  or  humerus. 


TUMORS  OF  BONE 


763 


Aneurism  of  Bone  is  a  term  formerly  much  employed  to  designate 
certain  highly  vascular  types  of  medullary  sarcoma,  in  which  pulsa- 
tion is  present  or  a  bruit  heard  on  auscultation.  As  a  rule  these 
tumors  are  of  the  round-  or  spindle-cell  variety,  although  these  symp- 
toms have  been  observed  in  myeloid  sarcoma.     Spontaneous  fracture 

is  frequent  in  these  cases — and  blood 
cysts  are  occasionally  found  in  their 
substance. 

Diagnosis. — The  diagnosis  of  bone 
sarcoma  in  the  early  stage  is  often 
impossible,  the  chief  difficulty  being 
in  excluding  chronic  osteomyelitis, 
gumma,  and,  when  the  disease  is  located 
in  the  extremity  of  a  bone,  chronic  dis- 
ease of  the  joint.  The  two  chief  symp- 
toms are  pain  and  tumor.  Gross  stated 
that  pain    is   the    initial  symptom  in 


Fig.  354. — Radiogram  of  chondroma 
of  bone. 


Fig.  355. — Sarcoma  of  femur. 


two-thirds  of  the  cases,  tumor  in  one-third.  In  the  writer's  opinion 
these  figures  should  be  reversed,  as  a  tumor  is  often  present  when  the 
patient  first  complains  of  pain,  although  unnoticed  up  to  that  time. 
Regarding  rapidity  of  growth  there  is  much  variation.  The  giant- 
cell  tumors  develop  very  slowly,  several  years  often  elapsing  before 
much  inconvenience  is  produced.  In  the  small  round-cell  tumors 
and  in  some  of  the  spindle-  and  mixed-cell  varieties,  the  growth  is 


764  DISEASES  OF  BONE 

exceedingly  rapid.  The  occurrence  of  a  progressively  growing  tumor 
of  a  long  bone  without  fever,  or  serious  impairment  of  the  function 
of  the  limb,  is  strongly  suggestive  of  sarcoma.  If  aspiration  fails  to 
reveal  the  presence  of  pus,  the  probability  of  sarcoma  is  increased. 
If  there  is,  in  addition,  the  presence  of  the  "egg-shell  crackle,"  or  an 
absence  of  joint-symptoms  in  tumors  situated  near  an  articulation, 
and  if  the  .r-rays  show  the  tumor  to  surround  the  shaft  of  the  bone  or 
to  expand  the  cortical  portion,  the  diagnosis  may  be  said  to  be  certain. 
In  all  doubtful  cases,  however,  an  exploratory  incision  and  the  removal 
of  a  section  of  the  tumor  for  microscopic  examination  is  indicated. 

Prognosis. — With  the  exception  of  myeloid  or  giant-cell  sarcomata, 
the  prognosis  in  malignant  disease  of  bone  is  exceedingly  grave.  While 
McCosh  has  reported  3  out  of.  7  cases  of  sarcoma  of  the  femur,  treated 
by  hip-joint  amputation,  well  from  4|  to  12  years  after  operation, 
few  such  favorable  statistics  have  been  recorded.  The  majority  of 
writers  who  have  collected  large  series  of  cases,  as  Gross,  Butlin,  and 
Coley,  state  that  the  number  of  permanent  cures  is  exceedingly  small. 
In  giant-cell  sarcoma  the  outlook  is  comparatively  favorable,  as  these 
tumors  apparently  do  not  give  rise  to  metastases,  and  early  and  com- 
plete removal  of  the  original  focus  will  generally  be  followed  by  a 
permanent  cure. 

Treatment. — The  treatment  of  bone  sarcoma  depends  largely  on  the 
nature  of  the  growth.  In  all  but  the  myeloid  variety  amputation 
should  be  practised  sufficiently  far  above  the  disease,  if  situated  in 
an  extremity,  to  insure  removal  of  the  entire  bone  and  surrounding 
tissues.  Thus  in  sarcoma  of  the  bones  of  the  leg,  amputation  at  the 
knee-joint  or  lower  third  of  the  thigh  is  to  be  advised.  In  disease  of 
the  lower  extremity  or  shaft  of  the  femur,  the  amputation  should  be 
at  the  hip-joint.  In  rapidly  growing  sarcoma  of  the  upper  extremity 
of  the  femur,  operation  is  inadvisable.  Sarcoma  of  the  bones  of  the 
forearm  should  be  treated  by  amputation  just  above  the  elbow-joint; 
those  of  the  shaft  and  lower  extremity  of  the  humerus,  at  the  shoulder- 
joint;  those  of  the  upper  extremity  of  the  humerus  should  be  treated 
by  removal  of  the  entire  shoulder-girdle.  This  has  been  the  recognized 
practice  in  the  past. 

Quite  recently  Cavaillon  and  Alamartine  have  advocated  more 
limited  operations,  on  the  ground  that  in  the  great  majority  of  instances 
the  disease  extends  by  direct  prolongations  from  the  original  growth 
rather  than  by  the  carrying  of  fragments  to  distant  parts  of  the  bone 
by  the  circulating  fluids.  In  support  of  this  view  they  quote  a  large 
series  of  cases  observed  for  a  number  of  years  in  which  a  greater  num- 
ber of  three-year  cures  were  obtained  by  the  less  mutilating  operations. 
The  subject  is  deserving  of  further  study.  If  the  tumor  is  of  the 
myeloid  variety,  all  surgeons  now  agree  that  amputation  is  unneces- 
sary, the  disease  being  thoroughly  removed  by  the  sharp  bone  curet 
or  lay  partial  resection.  WThen  curettage  is  employed,  every  vestige  of 
the  tumor  should  be  removed,  the  cavity  should  then  be  swabbed 


TUMORS  OF  BONE  765 

with  pure  carbolic  acid,  douched  with  alcohol,  and  tightly  packed  with 
gauze  to  avoid  hemorrhage,  which  is  often  free  and  difficult  to  control; 
or  if  bleeding  is  not  troublesome,  the  cavity  may  be  filled  with 
Mosetig-Moorhof  bone  plug.  In  myeloid  sarcoma  of  the  lower  jaw 
a  bridge  of  bony  tissue  should  always  be  left  to  prevent  deformity. 

Inoperable,  recurrent,  and  secondary  sarcoma  of  bone  may  be 
treated  by  the  Coley  fluid  or  the  mixed  toxins  of  Streptococcus  ery- 
sipelatis  and  Bacillus  prodigiosus,  the  aj-rays  or  radium. 

There  is  of  late  a  growing  tendency  among  surgeons,  even  in  the 
operative  cases,  to  resort  to  the  use  of  Coley's  toxins  immediately 
after  operation.  The  results  which  have  followed  this  method  of 
treatment,  as  recently  reported  by  Coley,  certainly  show  an  improve- 
ment over  the  treatment  by  operation  alone.1 

Multiple  Myeloma.— A  disease  characterized  by  multiple  myeloid 
tumors  in  different  bones  of  the  skeleton,  always  associated  with  the 
presence  of  albuminose  in  the  urine  The  disease  as  a  rule  occurs  late 
in  life,  and  affects  by  preference,  the  skull,  vertebra?,  or  ribs.  The 
tumors  rarely  grow  to  a  large  size,  but  occasionally  give  rise  to  press- 
ure symptoms,  particularly  of  the  brain  and  spinal  cord.  Another 
symptom  produced  by  this  disease  is  an  abnormal  fragility  of  the 
affected  bone,  often  resulting  in  spontaneous  fracture.  As  one  cannot 
hope  to  remove  all  of  the  diseased  areas,  the  only  treatment  at  present 
advised  is  to  remove  those  tumors  producing  pressure  symptoms. 

Carcinoma. — Carcinoma  of  bone  occurs  only  as  a  secondary  deposit. 
As  its  occurrence  under  these  circumstances  is  an  evidence  of  general 
infection,  no  treatment  is  advisable. 

1  Coley,  Surgery,  Gynecology  and  Obstetrics,  February,  1908. 


CHAPTER  XXVIII. 
INJURIES  AND  DISEASES  OF  JOINTS. 

Contusions. — Contusions  in  the  neighborhood  of  joints  are  of  fre- 
quent occurrence  from  all  manner  of  traumata.  They  are  accom- 
panied by  superficial  ecchymoses,  occasionally  by  deep  extravasation 
or  hemorrhage  into  the  synovial  sacs.  In  the  superficial  joints,  as 
the  knee,  elbow,  wrist,  and  ankle,  the  injuring  force  may  be  so  directed 
as  to  cause  a  bruising  of  the  synovial  membrane,  which  gives  rise  to 
an  acute  and  often  sickening  pain,  which  soon  disappears  unless  the 
trauma  causes  injury  to  the  ligaments  or  tendons  or  results  in  synovitis. 
In  the  majority  of  cases  no  treatment  is  required  other  than  temporary 
rest  of  the  articulation  and  the  application  of  a  firm  bandage. 

Sprains. — The  term  sprain  is  used  to  include  a  class  of  injuries 
somewhat  similar  in  character  to  the  preceding,  but  in  which  there 
occurs  in  addition,  a  rupture  or  at  least  a  severe  stretching  of  the 
ligamentous  structures,  muscles,  or  tendons  which  support  the  joint. 
These  injuries  in  the  majority  of  instances  are  produced  by  a  severe 
wrench  or  twist  of  the  articulation,  which  if  continued  would  result 
in  dislocation  or  fracture.  The  ankle  and  wrist,  on  account  of  their 
frequent  exposure  to  such  injuries,  are  the  joints  most  likely  to  be 
the  seat  of  sprain.  After  these  injuries  there  is  usually  a  rapid  swelling 
of  the  tissues  in  the  neighborhood  of  the  joint,  due  to  effusion  of 
blood  from  the  torn  vessels  into  the  extra-articular  structures  and 
often  into  the  joint  cavity  as  well.  This  is  followed  later  by  a  non- 
infectious inflammatory  reaction,  which  results  in  an  exudation  in 
the  subcutaneous  cellular  tissue,  muscles,  tendon  sheaths,  ligaments, 
and  synovial  membrane,  and  not  infrequently  in  the  synovial  sac. 

Symptoms. — The  symptoms  of  a  sprain  are  acute  pain  experienced 
at  the  moment  of  injury,  which  may  be  so  severe  as  to  preclude  the 
possibility  of  using  the  extremity  for  several  hours  or  days.  In  other 
cases  the  pain  subsides  after  a  few  moments,  but  reappears  on  any 
attempt  to  move  the  joint  or  use  the  extremity.  The  joint  appears 
swollen  and  is  tender  to  touch,  the  points  of  maximum  tenderness 
corresponding  to  the  location  of  the  ruptures  of  the  periarticular 
tissues  or  to  the  subsequently  developed  hematomata.  As  soon  as  the 
reactionary  inflammation  appears  there  are  heat  in  the  joint,  increased 
tumefaction,  often  redness,  and  a  greater  amount  of  tenderness  and 
pain  on  motion.  Ecchymoses  appear  and  fluctuation  often  may  be 
appreciated. 


SPRAINS  767 

These  symptoms  may  continue  for  a  variable  period,  depending  on 
the  extent  of  the  original  injury  or  the  treatment  received.  In  a 
certain  number  of  cases,  even  under  the  most  approved  methods  of 
treatment,  persistent  pain  on  motion  and  areas  of  tenderness  will 
remain  long  after  the  swelling  has  entirely  subsided.  In  these  cases 
there  is  generally  present  either  an  unrecognized  fracture,  a  subacute 
synovitis,  or,  in  the  case  of  the  ankle,  a  breaking  down  of  the  arch  of 
the  foot,  with  muscular  spasm. 

Treatment. — When  possible,  immerse  the  injured  part  in  a  pail  of 
hot  water,  and  then  gradually  add  hotter  water  until  the  temperature 
is  as  high  as  the  patient  can  bear.  The  joint  should  then  be  bandaged 
as  tightly  as  possible  without  causing  pain — a  rubber  or  flannel  bandage 
being  used.  The  first  effect  of  the  heat  is  to  diminish  the  pain  and  to 
contract  the  vessels,  thereby  limiting  the  hemorrhage  and  serous 
effusion.     The  use  of  the  elastic  bandage  applied  immediately  after 


Fig.  356. — A  method  of  applying  adhesive  plaster  strapping  for  sprain  of  the  ankle. 

(Whitman.) 

the  removal  of  the  limb  from  the  hot  water  serves  to  prevent  subse- 
quent congestion  and  exudation.  If  the  injury  has  been  slight  the 
joint  may  be  supported  by  an  adhesive  plaster  dressing  (Fig.  356), 
and  the  patient  allowed  cautiously  to  use  it.  If  the  injury  is  severe, 
absolute  rest  of  the  joint  should  be  advised,  and.  if  comfortable,  the 
bandage  should  be  allowed  to  remain  in  place  for  two  or  three  days. 

When  the  first  bandage  is  removed  the  joint  should  be  strapped 
with  adhesive  plaster.  This  prevents  swelling  and  gives  sufficient 
support  to  the  parts  to  enable  the  patient  to  use  the  limb  moderately 
without  discomfort. 

In  the  majority  of  instances,  however,  the  surgeon  is  not  called 
until  inflammatory  reaction  has  appeared  and  the  joint  is  in  a  condi- 
tion of  acute  hyperemia  and  edema.  In  these  cases,  rest  in  bed  with 
hot  fomentations  or  wet  dressings  of  aluminium  acetate  is  to  be  recom- 
mended for  a  few  days  until  the  inflammatory  symptoms  have  disap- 


768  INJURIES  AND  DISEASES  OF  JOINTS 

peared,  after  which  a  light  plaster  cast  may  be  applied  and  the  patient 
a  lowed  to  go  about  on  crutches.  From  the  first,  there  should  be 
continued  effort  to  increase  the  circulation  about  and  in  the  joint 
by  local  heat  (baking,  electric  light,  high  frequency  currents,  hot  water) 
and  by  active  massage.  In  all  cases  of  sprain,  especially  those  occurring 
at  the  ankle  or  wrist,  great  care  should  be  exercised  by  the  surgeon 
positively  to  exclude  the  presence  of  fracture  by  means  of  an  x-ray 
photograph,  for  no  mistake  is  more  easily  made  or  more  harshly  criti- 
cised. If  necessary,  the  joint  should  be  examined  under  general 
anesthesia. 

Penetrating  Wounds  of  the  Joints. — These  accidents  are  rare  except 
as  a  result  of  severe  traumata,  gunshot  or  stab-wounds.  While  the 
smaller  joints  occasionally  may  be  opened  and  the  untoward  results 
be  limited  to  a  slow  process  of  healing,  and  perhaps  a  permanent 
ankylosis,  wounds  of  the  large  joints  are  often  followed  by  loss  of  the 
limb  or  the  life  of  the  patient.  This  is  particularly  true  of  the  knee- 
joint,  the  synovial  membrane  of  which  is  justly  regarded  by  sur- 
geons as  one  of  the  most  vulnerable  tissues  of  the  body  to  septic  infec- 
tion, and,  on  account  of  its  peculiar  shape  and  anatomic  relations, 
is  of  all  the  joints  the  one  most  difficult  to  drain  and  successfully  to 
disinfect.  -  Moreover,  there  seems  to  be  in  the  synovial  membranes 
of  the  larger  joints  less  protective  power,  and  a  greater  amount  of 
septic  absorption  than  from  any  other  tissue  of  equal  size  and  vascu- 
larity. From  what  has  been  said,  it  wil  appear  that  the  danger  of 
these  injuries  is  solely  from  infection  and  the  treatment,  therefore, 
should  consist  in  measures  to  prevent  or  combat  it. 

Symptoms. — The  symptoms  of  a  penetrating  wound  of  a  joint  are, 
in  addition  to  the  visible  signs  of  a  wound  which  might  open  the 
synovial  cavity,  the  presence  of  a  flow  of  synovia  from  the  cutaneous 
opening.  This  is  a  clear,  syrupy  fluid,  which  is  fairly  abundant  from 
the  large  joints,  and  may  be  tinged  with  blood.  A  similar  fluid  may 
appear  in  such  a  wound  from  an  injured  extra-articular  bursa,  but  in 
these  cases  the  fluid  is,  as  a  rule,  less  abundant.  Inspection  will 
occasionally  reveal  the  presence  of  the  exposed  glistening  white 
articular  cartilage  in  the  bottom  of  the  wound.  Pressure  over  the 
uninjured  portions  of  the  joint  sac  will  sometimes  result  in  the  appear- 
ance in  the  wound  of  an  increased  amount  of  fluid  blood  or  synovia. 
Any  injury  to  the  joint  capsule  small  enough  to  need  the  aid  of  a  probe 
for  diagnosis  is  better  treated  expectantly  because  of  the  improbability 
of  a  probe  remaining  uncontaminated  during  its  passage  from  the  skin 
to  the  joint. 

Treatment. — In  all  cases  of  suspected  wound  of  a  joint  an  antiseptic 
dressing  immediately  should  be  applied  and  the  patient  removed  to 
some  place  where  an  aseptic  examination  can  be  made.  If  the  con- 
ditions are  such  that  an  aseptic  exploration  cannot  be  carried  out,  it 
is  wiser  to  allow  the  wound  to  heal  as  quickly  as  possible  under  the 
primary  dressing,  in  the  hope  that  infection  has  not  occurred,  or  that 


Fl.o AT l\c  CARTILAGE  IN  THE  JOINT  769 

the  resistance  of  the  individual  is  sufficient  to  cope  with  it  without 
assistance,  and  to  inter  ere  only  in  case  evidences  of  sepsis  appear.  In 
addition  to  the  primary  dressing,  the  limb  should  be  immobilized,  and 
the  patient  placed  in  bed.  The  bowels  should  be  freely  moved,  and 
diuresis  favored  by  copious  draughts  of  pure  water  to  assist  in  elimi- 
nation of  any  toxins  that  may  develop.  If  evidences  of  septic  arthritis 
appear,  the  joint  should  be  treated  in  a  manner  presently  to  be 
described.  If  the  conditions  are  such  as  to  insure  an  aseptic  examina- 
tion of  the  wound,  the  surgeon  should  first  pack  the  external  wound 
with  sterile  gauze,  then  scrub  and  shave  the  neighboring  parts,  after 
which  the  packing  should  be  removed  and  the  cutaneous  wound 
cleansed  thoroughly  with  soap  and  water  followed  by  prolonged 
irrigation  with  hot  saline  solution.  In  injuries  caused  by  oily  bodies 
such  as  machinery,  a*  preliminary  scrubbing  with  benzine  will  remove 
much  of  the  gross  material.  Tincture  of  iodin  copiously  applied  to 
a  lacerated  wound  has  a  wide  vogue  among  railway  surgeons.  If 
the  wound  is  found  to  penetrate  the  joint  cavity  with  slight  injury 
to  the  capsule  and  intra-articular  structures  it  should  be  sufficiently 
enlarged  to  allow  thorough  irrigation  of  the  sac  with  sterile  salt 
solution.  The  wound  should  then  be  closed  with  superficial  drainage 
and  a  bulky  aseptic  dressing  applied.  With  only  slight  laceration  of 
the  joint  structure,  the  overlying  tissues  may  be  loosely  sutured  with- 
out drainage.  If  the  tissue  destruction  is  very  great  and  infection 
positive,  a  rubber  tube  drain  is  sutured  securely  to  the  skin  so  that  its 
deep  end  reaches  but  does  not  penetrate  the  joint  cavity.  Following 
this  the  most  careful  watch  is  kept  for  evidence  of  suppuration  in  the 
joint  which  is  then  appropriately  treated.  It  is  only  by  these  non- 
interfering  procedures  that  healing  of  the  joint  may  be  hoped  for 
without  ankylosis,  for  here  as  in  injuries  to  the  tendon  sheaths,  large 
drains  not  only  abrade  the  joint  surfaces  but  serve  as  ready  guides  for 
bacteria  invading  from  the  skin. 

If  the  wound  remains  aseptic  the  dressing  should  not  be  changed 
for  a  week  or  ten  days. 

Floating  Cartilage  in  the  Joint. — Free  cartilaginous  masses  are 
occasionally  encountered  in  the  larger  joints,  especially  the  knee. 
They  represent  either  small  fragments  broken  off  from  the  articular 
surfaces  by  traumata,  or,  more  commonly,  chondrified  portions  of  the 
synovial  folds  or  fringes  which  have  become  detached  by  the  move- 
ments of  the  articulation. 

Symptoms. — When  these  movable  bodies  are  caught  between  the 
articular  surfaces  of  the  bones  they  give  rise  to  a  sudden  acute  pain, 
with  "locking  of  the  joint."  The  patient  often  falls  to  the  ground 
and  is  unable  to  move  the  limb.  Forcible  flexion  and  extension  will 
sometimes  cause  the  symptoms  to  disappear.  Careful  palpation  will 
generally  reveal  the  presence  of  the  cartilage. 

Treatment. — The  treatment  should  consist  in  aseptic  incision  and 
removal  of  the  foreign  body.  The  joint,  however,  should  never  be 
49 


770  INJURIES  AND  DISEASES  OF  JOINTS 

opened  for  this  purpose  unless  the  cartilage  is  distinctly  felt  and  held 
by  the  fingers  of  the  surgeon,  for  extensive  exploration  of  the  joint 
cavity  is  often  unsuccessful  and  accompanied  by  grave  risk  of  infection. 

Dislocation  and  Injury  to  the  Semilunar  Cartilage  of  the  knee  joint 
may  produce  similar  symptoms,  and  is  described  on  page  903. 

For  fractures  entering  the  joint  and  dislocations  see  chapters  on 
Fractures  and  Dislocations,  pages  806  and  873. 

Inflammation  of  Joints. — In  considering  joint  inflammations  it  is 
well  to  remember  that  the  structures  entering  into  the  formation  of  a 
joint  are  composed  of  tissues  originating  in  the  same  mesodermal  layer, 
and  capable  of  transformation  from  one  connective  tissue  form  to 
another  through  metaplasia,  so  that  synovial  membrane  may  become 
cartilage  or  bone,  and  bone  be  transformed  into  fibrillary  connective 
tissue,  etc.  The  bones  near  the  joint  contain  the  growing  centres 
and  numerous  blind  end  vessels.  The  cartilage  is  avascular  and 
almost  incapable  of  repair  or  of  any  immunizing  activity,  and  is  the 
first  tissue  to  be  destroyed  by  infection.  The  synovial  membrane  is 
composed  of  flattened  connective  tissue  cells  rich  in  intercellular 
substance.  The  synovial  fluid  is  a  liquefied  intercellular  substance 
and  not  a  secretion.  The  blood  supply  of  the  synovial  membrane  is 
poorly  connected  with  that  of  the  periarticular  tissues;  the  vessels 
in  the  joint  fringes  have  a  coiled  appearance  making  them  act  more 
or  less  as  closed  end  vessels.  The  synovial  lymphatics  have  no  lymph 
stomata  as  in  other  closed  cavities,  which  perhaps  explains  the  fact 
that  joints  seldom  share  in  general  anasarca,  and  the  difficulty  with 
which  joint  effusions  are  absorbed.  Nerves  are  numerous  in  the 
synovial  membrane  but  absent  in  the  cartilage. 

In  the  normal  functional  activity  of  a  joint,  there  is  constantly  a 
certain  amount  of  trauma  incident  to  exercise,  so  that  in  health  the 
joint  is  in  a  state  of  balance  between  irritation  of  the  joint  structures 
and  the  reparative  or  adaptive  power  of  the  tissues;  but  when  the 
range  of  normal  tolerance  is  passed  by  the  trauma,  or  foreign  irritating 
substances  are  introduced  as  bacteria  or  toxic  agents,  or  when  the 
adaptive  powers  of  the  body  or  of  the  joint  become  lowered  as  by 
exposure  or  disease,  the  balance  becomes  disturbed  and  abnormal 
adaptive  processes  occur  which  we  call  inflammation. 

Etiology. — The  chief  exciting  etiological  factors  in  joint  inflammation 
are  mechanical  trauma,  chemical  agents  or  bacteria,  acting  on  a  joint 
with  normal  or  lowered  resistance. 

Mechanical  irritation  may  be  caused  by  accidental  trauma;  by 
excessive  exercise,  as  in  forced  marches  where  examination  of  the  joint 
fluid  has  revealed  the  characteristics  of  an  exudate;  by  static  changes 
with  bearing  of  the  weight  by  improper  surfaces;  by  loose  foreign 
bodies,  hypertrophied  synovial  fringes,  osteophytes,  movable  joint 
cartilages;  and  possibly  by  crystals  of  uric  acid. 

Chemical  irritation  may  be  caused  by  homogentisic  acid,  uric  acid, 
lead,   decomposition  products  as  in  hemarthrosis,   and  toxins  from 


INFLAMMATION  OF  JOINTS  771 

the  intestine  or  from  other  bacterial  foci,  as  in  the  so-called  tuber- 
culous pseudorheumatism  of  Poncet,  in  which  toxins  from  a  distant 
tuberculous  focus  are  believed  to  cause  an  acute  arthritis. 

Of  the  bacterial  irritants,  there  may  be  mentioned  the  streptococcus, 
staphylococcus,  gonococcus,  pneumococcus,  and  many  other  varieties 
of  pathogenic  micro-organisms.  Many  of  these  have  been  recovered 
from  inflamed  joints,  as  well  as  from  the  anatomically  related  lymph 
nodes.  Rosenow  has  recently  shown  that  practically  all  varieties  of 
acute  and  chronic  arthritis  may  be  produced  by  direct  infection  of  a 
joint  by  the  various  strains  of  the  streptococcus.  In  his  interesting 
experimental  work,  he  has  shown  that  by  cultural  changes  or  by 
passing  a  given  organism  through  animals,  he  can  effect  marked  mor- 
phological and  cultural  alterations;  changing  streptococci  of  one 
variety  into  another, 'and  again  into  pneumococci  or  into  intermediate 
forms  such  as  the  micrococcus  of  Poynton  and  Paine,  found  in  acute 
articular  rheumatism.  Experimentally  it  has  been  found  that  the 
same  organism,  because  of  these  variations,  may  cause  in  joints,  inflam- 
mations from  the  most  acute  and  fatal,  to  those  of  mild  and  persistent 
course.  Often  one  injection  will  cause  in  the  same  animal  several 
varieties  of  arthritis. 

All  bacteria  do  not  cause  joint  inflammation,  but  only  those  which 
have  a  special  affinity  for  joint  tissues.  The  Streptococcus  viridans 
which  may  cause  severe  heart  lesions  without  injuring  the  joints, 
when  it  has  been  converted  by  mutation  into  a  Streptococcus  hemo- 
lyticus  causes  the  reverse  to  occur. 

The  three  types  of  causes  mentioned  above  may  act  singly  or  in 
combination,  as  in  those  joints  which  becomes  infected  with  the  added 
element  of  trauma  or  gout. 

The  second  factor  in  joint  inflammation  is  the  adaptive  power  of 
the  joints.  In  old  age  the  joint  becomes  worn  out,  it  no  longer  cares 
for  the  trauma  which  in  youth  it  could  resist.  The  same  thing  occurs 
in  younger  individuals  when  the  joint  is  deprived  of  its  nerve  supply 
or  otherwise  weakened  as  by  exposure,  acute  disease,  etc. 

The  source  of  chemical  irritants  is  variable,  toxins  may  arise  from 
the  intestines,  from  a  tuberculous  or  septic  focus,  from  errors  in  diet, 
or  from  metabolic  disturbance  as  in  gout. 

Of  the  bacteria;  the  streptococcus  in  the  majority  of  instances  is 
derived  from  the  faucial  tonsil,  from  pyorrhea  alveolaris,  from  the 
nasal  cavity  or  accessory  sinuses  and  from  the  seminal  vesicles  where 
they  may  be  found  long  after  the  disappearance  of  the  gonococcus.  The 
gonococcus  in  males  is  found  most  frequently  in  the  prostate  and  seminal 
vesicles,  in  women  in  the  uterine  tubes  and  cervical  canal,  rarely  in 
an  old  Bartholinian  abscess.  The  staphylococcus  comes  usually  from 
some  acute  focus  as  a  folliculitis  or  osteomyelitis.  The  pneumococcus 
is  found  less  frequently  after  pneumonia  than  otherwise. 

Pathology. — The  pathologic  changes  in  an  inflamed  joint  vary  with 
the  type  of  the  inflammation  and  the  acuteness  or  chronicity  of  the 


772  INJURIES  AND  DISEASES  OF  JOINTS 

process.  These  together  with  the  symptomatology  and  treatment  will 
be  considered  later  with  a  description  of  the  various  clinical  types. 

Arthritis. — The  classification  of  arthritis  is  still  in  the  formative 
stage.  Assuming  that  the  etiological  classification  is  the  most  desir- 
able this  will  be  given  as  far  as  possible,  and  other  clinical  types  of 
uncertain  etiology  mentioned  under  their  clinical  titles. 

The  division  into  acute  and  chronic  is  convenient  for  classification 
and  will  be  used,  but  it  must  be  remembered  that  there  is  an  unbroken 
gradation  from  the  most  acute  arthritis  to  the  mildest  chronic  joint 
disease,  so  that  the  terms  indicate  extreme  grades  of  the  same  process. 

Acute  Arthritis. — Acute  arthritis  may  arise  from  trauma,  bacteria 
or  chemical  poisons  or  toxins. 

Acute  Traumatic  Arthritis  (serous  synovitis)  may  be  caused  by  a 
blow  or  wrench  of  the  joint,  with  injury  to  ligaments  and  cartilage; 
by  hemorrhage  into  the  joint;  and  by  foreign  bodies.  There  is  injury 
to  the  tissues  varying  with  the  site  and  degree  of  the  trauma,  also  an 
exudate  of  serum,  blood,  small  amounts  of  fibrin  and  later  some  leuko- 
cytes. The  joint  cavity  is  distended  and  the  ligaments  somewhat 
loosened.  The  process  usually  terminates  in  resolution,  but  if  the 
cause  persists,  it  may  become  chronic. 

Symptoms. — The  symptoms  are  sudden  sharp  pain,  later  becoming 
dull,  constant,  and  always  increased  by  motion:  swelling,  reaching  its 
maximum  in  about  forty-eight  hours;  tenderness,  moderate  heat  and, 
rarely,  redness  of  the  skin.  The  swelling  obliterates  the  normal  out- 
lines of  the  joint,  gives  rise  to  fluctuation  and  causes  the  joint  to  be 
held  in  a  position  to  allow  the  greatest  distension  of  the  capsule. 

Signs  of  effusion  into  the  larger  joints.  In  the  shoulder-joint  there 
is  general  swelling  in  the  region  of  the  articulation  which  lifts  the 
deltoid  muscle  and  may  be  felt  in  the  axilla.  It  is  distinguished  from 
the  swelling  due  to  inflammation  of  the  subdeltoid  bursa  by  the 
fact  that  in  the  latter  condition  the  bursal  swelling  is  in  the  space 
beneath  the  centre  of  the  muscle  and  cannot  be  felt  in  the  axilla, 
whereas  in  joint  effusion  the  swelling  extends  to  or  beyond  the  anterior 
and  posterior  borders  of  the  muscle  and  is  especially  noticeable  along 
the  bicipital  groove.  In  the  elbow-joint  an  effusion  causes  a  bulging 
posteriorly  on  either  side  of  the  olecranon  and  triceps  tendon.  Inflam- 
mation of  the  olecranon  bursa  gives  rise  to  a  swelling  over  the  olec- 
ranon. In  the  wrist-joint  there  is  general  tumefaction  anteriorly  and 
posteriorly,  which  lifts  the  tendons  and  is  sharply  limited  above  and 
below  by  the  radiocarpal  and  carpometacarpal  joints.  Inflammation 
of  the  common  flexor  tendons  bursa  causes  an  hour-glass  swelling 
on  the  flexor  side  of  the  wrist  above  and  below  the  annular  ligament. 
Effusion  into  the  hip-joint  causes  a  fulness  about  the  joint  which  is 
most  noticeable  in  the  post-trochanteric  region  and  in  the  region  of 
Scarpa's  triangle.  The  limb  is  partly  flexed,  abducted  and  rotated  out- 
ward. Iliofemoral  bursitis  causes  a  swelling  on  the  inner  aspect  of  the 
thigh  only,  and  in  gluteal  bursitis  the  swelling  is  limited  to  the  buttock. 


ACUTE  INFECTIVE  ARTHRITIS  773 

In  the  knee-joint  the  effusion  causes  obliteration  of  the  normal  depres- 
sions on  either  side  of  the  patella  and  its  tendon.  The  swelling  is 
especially  marked  above  the  patella  as  an  oval  fluctuating  tumor  which 
may  extend  upward  for  two  or  more  inches  and  in  children  to  the 
middle  of  the  thigh.  The  patella  floats  hut  may  he  made  to  click 
against  the  condyles  by  quick  firm  pressure.  These  signs  are  absent 
in  prepatellar  bursitis  in  which  case  the  fluctuating  swelling  lies 
anterior  to  and  below  the  patella.  In  pretibial  bursitis  the  swelling 
bulges  the  space  on  either  side  of  the  patellar  tendon  and  is  triangular 
in  shape  with  the  base  directed  upward,  and  the  apex  pointing  to  the 
tubercle  of  the  tibia.  In  the  ankle-joint  the  effusion  bulges  and  effaces 
the  normal  depressions  between  the  malleoli  and  the  tendo  Achilles. 
The  flexor  tendons  are  raised  from  the  bone  and  fluctuation  generally 
can  be  detected. 

Treatment. — Treatment  is  purely  local;  rest  on  a  splint  with  hot  or 
cold  applications;  later  massage,  moderate  use,  hydrotherapy  and 
pressure  to  the  joint  by  a  bandage,  or  by  adhesive  plaster.  If  the 
effusion  is  severe  or  persistent,  aspiration  by  a  trocar  and  cannula 
under  strict  asepsis  is  indicated. 

The  prognosis  depends  on  the  etiological  factor  and  should  be 
guarded  until  intra-articular  derangement  can  be  excluded.  In  most 
instances  recovery  follows  the  employment  of  the  measures  outlined 
above.  If,  however,  the  joint  after  injury  is  still  further  irritated  by 
functional  use,  the  condition  may  become  chronic.  This  will  be 
described  later  in  the  chapter  under  Chronic  Serous  Synovitis. 

Acute  Infective  Arthritis. — Etiology. — Acute,  infective  arthritis 
occurs  as  a  result  of  a  penetrating  wound  or  by  infection  reaching 
the  joint  through  the  blood  or  lymph  currents.  Nearly  all  the  bacteria 
mentioned  above  have  been  found  in  acute  septic  arthritis.  Pre- 
disposing causes  are  trauma  and  general  depression  of  health.  While 
it  may  be  true  that  the  toxins  of  bacteria  coming  from  other  foci  may 
cause  inflammation,  yet  the  increasing  frequency  with  which  bacteria 
are  isolated  from  these  joints  tend  to  lessen  the  number  of  such  cases. 

Pathology.  —  The  pathology  is  that  of  any  acute  inflammation, 
congestion,  exudation  of  serum,  fibrin  (dry  septic)  and  pus,  with  necro- 
sis, either  microscopic  or  gross,  of  all  tissues  affected.  The  process 
begins  in  the  subchondral  bone  or  rarely  in  the  synovial  membrane, 
and  is  due  to  the  lodgement  in  these  structures  of  bacteria  carried  in 
the  circulation  from  some  primary  focus.  The  process  spreads  to  the 
other  joint  structures  and  may  progress  until  it  destroys  the  joint  or 
the  life  of  the  individual;  or,  resolution  may  take  place  with  complete 
restoration  of  function,  repair  by  granulation  tissue,  fibrous,  cartilag- 
inous or  bony  ankylosis.  In  rare  instances  the  process  may  continue 
as  a  chronic  infective  arthritis. 

Symptoms. — The  onset  is  sudden  or  may  extend  over  several  days, 
and  is  often  masked  by  the  primary  infective  process.  Febrile  symp- 
toms  often  with  chill  usually  precede  the  pain.    This  in  turn,  especially 


774  INJURIES  AND  DISEASES  OF  JOINTS 

when  the  focus  is  in  the  bone  at  some  distance  from  the  joint  surface, 
may  precede  any  signs  in  the  joint.  When  the  joint  becomes  involved, 
there  is  limitation  of  motion  by  muscular  spasm,  the  joint  being  held 
in  the  position  to  give  the  greatest  volume  to  the  joint  cavity,  swelling 
with  fluctuation,  heat,  redness,  great  tenderness  and  pain  of  dull, 
severe,  continuous  character,  made  excruciating  by  any  movement. 
With  resolution,  which  may  occur  at  any  time,  and  at  any  stage  of 
the  process,  the  symptoms  subside,  the  joint  remains  moderately  stiff 
for  several  weeks  and  eventually  recovers  more  or  less  complete  func- 
tion. If  the  process  advances,  the  pus  bursts  through  the  capsule, 
gives  rise  to  a  periarticular  cellulitis,  and  may  rupture  externally. 
Death  exceptionally  may  occur  before  there  are  any  marked  signs  in 
the  joint. 

Clinical  Varieties. — The  clinical  and  pathological  picture  varies 
somewhat  with  the  different  organisms. 

The  Streptococcus  hemoliticus  causes  a  virulent  monarticular,  less 
often  polyarticular  arthritis,  either  causing  death  by  sepsis  before 
there  is  much  more  than  a  seropurulent  exudate,  or  goes  on  to  great 
destruction  of  cartilage.    It  rarely  affects  the  heart. 

The  Streptococcus  viridans  causes  more  often  a  polyarthritis  with 
less  exudation  in  the  joint  but  considerable  infiltration  of  the  peri- 
articular structures,  tendonous  insertions  and  flat  muscles,  and  more 
frequently  involves  the  heart. 

The  diplococcus  rheumaticus  (Poynton  and  Paine)  is  said  to  cause 
the  polyarthritis  of  acute  rheumatic  fever,  with  feeding  of  infection 
from  joint  to  joint,  periarticular  rather  than  intra-articular  infiltra- 
tion and  severe  heart  involvement.  Rosenow  believes  that  this  may 
be  a  mutation  form  of  streptococcus. 

The  pneumococcus  causes  usually  a  monarticular  lesion,  affects  the 
large  joints,  especially  the  shoulder,  where  there  is  an  exudate  of  thin 
yellow  pus  with  mild  or  severe  injury  to  the  joint.  It  usually,  but  not 
always,  follows  pulmonary  inflammation. 

There  are  many  other  varieties  of  streptococcus  causing  arthritis, 
but  their  differentiation  is  as  yet  imperfect.  It  may  be  that  they  are, 
as  Rosenow  believes,  all  forms  of  the  same  organism  with  virulence, 
and  morphological  and  cultural  characteristics  changed  by  their 
growth  in  the  body  and  producing  all  types  of  arthritis  depending 
upon  these  factors. 

Staphylococcus  arthritis  is  not  common,  is  usually  one  of  a  number 
of  pyemic  foci;  the  course  may  be  very  chronic  and  the  numerous 
foci  develop  at  considerable  intervals. 

Gonorrheal  arthritis  occurs  rarely  during  the  acute  stages  of  the 
primary  disease  but  may  occur  at  any  time  during  its  existence, 
especially  after  involvement  of  the  prostate,  seminal  vesicles,  Bartho- 
lin's gland,  cervix  and  Fallopian  tubes.  The  clinical  picture  varies 
from  an  acute  polyarthritis,  indistinguishable  from  acute  rheumatic 
fever,  to  a  chronic  monarthritis  with  slight  persistent  effusion  and 


ACUTE  INFECTIVE  ARTHRITIS  775 

stiffness.  Usually  there  is  an  acute  polyarthritis  of  moderate  degree 
with  final  localization  in  one  joint,  which  becomes  a  characteristic 
chronic  infective  arthritis,  with  changes  most  marked  in  the  periarticu- 
lar structures.  Rarely  there  is  a  chronic  progressive  polyarthritis, 
distinguished  from  the  other  usual  forms  only  by  the  isolation  of  the 
organism  or  the  complement  fixation  test.  There  is  a  chronic  poly- 
arthritis appearing  long  after  the  gonococcus  has  disappeared  from 
the  body  and  is  probably  due  to  persistence  of  organisms  secondary 
to  the  gonococcus  in  the  prostate  or  seminal  vesicles. 

The  acute  joint  infections,  caused  by  the  colon  bacillus  and  typhoid 
bacillus,  are  usually  monarticular  and  secondary  to  bone  involvement. 

Treatment. — In  the  treatment  of  acute  infectious  arthritis,  one  should 
remember  that  in  every  instance  in  which  the  symptoms  are  ushered 
in  by  a  definite  chill,.destruction  of  tissue  leading  to  obstinate  or  perma- 
nent ankylosis  will  follow  unless  the  intra-articular  tension  is  speedily 
relieved  by  extension,  aspiration,  or  arthrotomy.  In  the  milder  cases 
without  marked  or  progressive  toxemia,  removal  of  the  exudate  by 
aspiration,  followed  by  irrigation  with  sterile  salt  solution  and  the 
injection  of  10  to  30  cm.  of  an  antiseptic  fluid,  is  to  be  recommended. 
This  should  be  repeated  as  often  as  the  joint  fills,  usually  every  second 
or  third  day.  At  each  aspiration  all  of  the  infected  fluid  should  be 
evacuated.  Of  the  antiseptic  agents,  0.5  per  cent,  phenol  in  water 
or  1  per  cent,  formalin  in  glycerin  are  the  most  useful.  Often  from 
six  to  ten  treatments  are  necessary  to  bring  about  a  cure.  The  results 
of  this  treatment  often  are  strikingly  satisfactory,  as  complete  res- 
toration of  function  is  the  rule  in  favorable  cases.  In  cases  of  infec- 
tious arthritis  following  a  penetrating  wound,  and  in  all  cases  with 
rapidly  advancing  toxemia,  arthrotomy,  thorough  irrigation  and 
drainage  are  to  be  advised.  This  is  best  accomplished  by  making 
several  incisions,  and  draining  with  rubber  tubes  introduced  to  but 
not  within  the  synovial  cavity. 

In  the  severest  cases  threatening  life,  the  Mayo  operation  is  indi- 
cated. This  operation,  which  originally  was  performed  on  the  knee 
joint,  consists  in  a  semilunar  incision  from  one  condyle  to  the  other 
across  the  front  of  the  joint  through  the  patellar  tendon.  When  the 
joint  is  freely  opened  by  this  method,  the  leg  is  acutely  flexed,  the 
crucial  ligaments  severed,  and  the  capsule  sufficiently  divided  to 
expose  freely  every  recess  of  the  synovial  membrane.  The  parts  are 
then  thoroughly  cleansed,  the  leg  fixed  in  the  flexed  position  by  suit- 
able apparatus,  and  the  exposed  joint  surfaces  packed  with  wet 
bichloride  or  formalin  gauze.  Improvement  in  the  general  septic 
symptoms  almost  invariably  follows  this  procedure  if  carried  out 
before  a  blood  infection  has  occurred,  but  many  weeks  are  sometimes 
required  before  all  evidences  of  sepsis  have  subsided.  After  con- 
valescence from  the  infection  is  thoroughly  established,  the  ends  of 
the  bones  should  be  excised  or  all  necrosed  portions  of  the  cartilage 
removed,  the  leg  extended  and  firmly  fixed  by  a  posterior  splint  or 


770  INJURIES  AND  DISEASES  OF  JOINTS 

plaster  cast.  The  skin  flaps  can  be  easily  approximated  after  excision 
of  the  bones,  and  should  be  held  together  with  two  or  three  sutures, 
the  rest  of  the  wound  being  left  freely  open  for  drainage.  Bony  union 
eventually  takes  place,  and  a  useful  but  stiff  limb  will  result. 

As  soon  as  the  tension  in  the  joint  is  relieved,  or  where  the  process 
is  mild  or  polyarticular  in  type,  as  in  the  so-ealled  acute  rheumatic 
fever,  an  effort  should  be  made  to  locate  and  remove  the  source  of 
infection,  as  a  diseased  tonsil,  furuncle,  alveolar  abscess  or  Rigg's 
disease;  and  certain  arthrotropic  drugs  as  the  salicylate  of  sodium 
may  be  employed.  Efforts  should  be  made  to  increase  the  resistance 
of  the  individual  by  good  food,  fresh  air  and  other  hygienic  measures; 
elimination  of  the  toxins  favored  by  catharsis,  and  an  abundance  of 
drinking  water.  Much  may  be  expected  by  the  judicious  employment 
of  autogenous  vaccines,  and  occasional  benefit  is  derived  from  the  use 
of  antistreptococcus,  antigonococcus  and  other  sera. 

These  measures  should  be  continued  with  local  rest,  hot  or  cold 
applications  and  separation  of  the  joint  surfaces  by  position  or  traction. 
As  the  process  subsides,  massage,  passive  motion,  hot.  and  cold  douches 
and  electricity  will  be  indicated  to  restore  motion  and  increase  the 
nutrition  of  the  muscles. 

Gouty  Arthritis. — Gouty  arthritis  is  the  clearest  example  of  chemical 
irritation  of  a  joint,  although  toxins  from  various  sources  as  men- 
tioned above  may  be  excitants.  True  gout  attacks  by  preference  the 
metatarsophalangeal  joint  of  the  great  toe  and  the  joints  of  the  hand, 
rarely  the  knees,  elbows  or  the  other  large  joints.  It  is  a  manifestation  of 
a  general  disease  of  metabolism  characterized  by  the  deposit  periodically 
of  sodium  biurate  crystals  in  cartilage  and  certain  connective  tissues. 
In  the  joint  this  gives  rise  to  an  acute  inflammation  with  effusion,  and 
later  cup-shaped  ulcerations  of  the  cartilage,  thickening  of  the  peri- 
articular structures,  moderate  bone  formation,  and  fibrous  or  bony 
ankylosis.  The  diagnosis  is  established  by  the  determination  of  errors 
in  uric  acid  metabolism,  tophi  in  the  lobes  of  the  ears  and  by  the 
peculiar  acute  insinuating  pain  coming  on  at  night.  The  treatment  is 
purely  medical,  with  drugs,  baking,  hydrotherapy  and  massage. 

Chronic  Arthritis. — The  classification  of  chronic  arthritis  is  also  in 
the  formative  stage.  Assuming  that  the  most  important  factor  in 
the  treatment  is  the  removal  of  the  cause,  we  will,  as  far  as  possible, 
adopt  an  etiological  classification,  present  the  cases  as  they  come 
under  this  heading  and  then  follow  with  several  clinical  types  in  which 
the  etiology  is  very  obscure. 

Secondary  infective  arthritis  describes  those  cases  which  are  merely 
the  terminal  stage  of  an  acute  septic  arthritis.  Chronic  Primary 
Progressive  Polyarthritis  is  the  name  given  by  Barker  to  include 
all  of  those  cases  with  a  supposedly  infectious  origin,  characterized 
by  a  primary  chronic  progressive  course  of  mild  inflammation  in  the 
joints.  The  name  distinguishes  it  from  secondary  infection  arthritis 
merelv  in  that  the  chronic  character  of  the  disease  is  primary  and 


CHRONIC  ARTHRITIS  111 

has  not  followed  a  previous  severe  infection  of  the  joint,  although  as 
in  acute  arthritis,  the  lesion  is  probably  secondary  to  an  infections 
focus  elsewhere  in  the  body.  It.  is  meant  to  include  those  conditions 
which  have  been  given  the  name  arthritis  deformans,  rheumatoid 
arthritis-,  chronic  rheumatism,  hypertrophic  osteo-arthritis,  arthritis 
ankylopoitica,  and  Still's  disease. 

Etiology. — The  etiologic  factor  in  these  cases,  is  a  mild  chronic 
irritation  of  the  joint  structures.  The  bacteria  which  were  mentioned 
under  general  considerations  of  the  subject  have  all  been  found  in 
chronic  joint  disease.  Of  these  the  streptococcus  is  the  most  interesting 
and  important,  and  has  been  isolated  in  its  various  cultural  and  morpho- 
logical varieties.  In  a  series  of  joints  in  which  no  organism  could  be 
isolated,  Hastings  found  that  40  per  cent,  gave  a  complement  fixation 
test  of  streptococcus  -viridans.  Experimentally  the  strains  of  strep- 
tococcus have  been  made  to  cause  all  grades  of  arthritis  by  one  injec- 
tion. A  streptococcus  isolated  from  a  case  of  polyarthritis  in  the 
human  patient,  injected  intravenously  into  a  rabbit,  caused  poly- 
arthritis similar  to  that  in  the  human  and  was  recovered  in  pure  culture 
from  the  joints  (Billings). 

Other  irritating  factors  are  the  mechanical  irritations  due  to  changes 
in  the  posture  of  the  patient  with  alteration  of  the  weight  bearing 
surfaces,  and  secondly  by  subsequent  intra-articular  inflammatory 
growths.  Chemical  irritation  is  proven  frequently  by  alteration  in 
the  uric  acid  metabolism  of  the  body,  indeed  gout  is  considered 
by  many  to  be  one  of  the  most  important  predisposing  causes  to  the 
localization  of  the  infection,  even  though  severe  gouty  symptoms  may 
be  absent.  The  second  factor  in  joint  inflammation  is  the  adaptive 
power  of  the  articular  structures.  An  organism  which  might  be 
destroyed  even  though  it  arrived  in  the  joint  structure,  would  in  one 
of  altered  adaptive  powers,  cause  inflammation.  It  is  for  that  reason 
that  exposure  to  cold  and  wet,  severe  muscle  strain,  bad  habits  of 
eating,  constipation,  intestinal  fermentation,  often  decay  of  the  teeth, 
or  other  chronic  infections  from  wThich  the  joint  organism  can  be 
excluded,  become  important  predisposing  factors  to  the  activities  of 
the  actual  infecting  organism.  The  portal  of  entrance  of  the  bacteria 
in  the  majority  of  cases,  is  the  faucial  tonsil,  next  disease  of  the  teeth, 
thirdly,  disease  of  the  genito-urinary  tract,  and  fourthly,  the  sinuses 
of  the  nose. 

Pathology. — The  initial  lesion  is  either  in  the  subchondrial  trabecu- 
lated  bone,  or  in  the  synovial  sheath  or  fibro-areolar  cartilage,  where 
there  is  an  initial  necrosis  followed  by  the  exagerated  processes  of 
repair.  This  develops  into  two  pathological  types.  In  the  first  the 
exudative  and  granulation  tissue  formations  predominate,  in  the 
second  the  production  of  scar  tissue  without  marked  hyperplasia,  In 
the  first  there  is  early  separation  of  the  cartilage  by  the  subchondral 
inflammation,  necrosis,  fibrillation,  separation  of  large  and  small 
fragments  with  baring  of  the  ends  of  the  bone  which  through  pressure 


778  INJURIES  AND  DISEASES  OF  JOINTS 

become  eburnated.  The  bones  become  covered  with  granulation 
tissue  and  show  lipping  at  the  edges  of  the  cartilages  and  formation 
of  bony  osteophytes  which  break  off  and  become  loose  bodies.  There 
is  moderate  exudation.  The  joints  may  become  distended  with  fluid 
and  with  the  shaggy  synovial  proliferation,  the  capsule  becomes 
stretched,  and  various  degrees  of  dislocation  occur  as  a  result  of  mus- 
cular traction. 

In  the  second  form,  along  with  mild  destructive  processes,  there  is 
a  great  increase  of  connective  tissue  with  only  slight  overgrowth  of 
bone  and  synovia,  so  that  the  joint  becomes  stiff  with  fibrous  and 
often  later  bony  ankylosis.  While  these  two  pictures  are  distinct,  it 
must  be  remembered  that  they  represent  only  the  extreme  types  and 
there  may  be  all  stages  between.  Microscopic  examination  of  the 
joint  structures  show  that  there  is  little  arteriosclerosis  but  great 
endothelial  proliferation  in  the  smaller  vessels,  possibly  causing  retar- 
dation of  oxydation  which  favors  the  growth  of  the  bacteria.  Numer- 
ous lymphocytes  are  found  in  the  subintimal  layers  of  the  blood- 
vessels. Bacteria  occasionally  are  found  in  the  joint  fringes,  peri- 
articular structures,  bone,  bloodvessels,  and  rarely  in  the  joint  fluid. 
Changes  in  the  structures  near  the  joint  are,  infiltration  and  atrophy 
of  the  muscular  attachments;  atrophic  processes  of  the  bone,  first 
absorption  with  rarefaction  and  the  formation  of  cysts,  secondly  a 
thinning  of  the  cortex.  These  processes  are  more  marked  in  the 
inflamed  joints  than  in  those  simply  suffering  from  the  atrophy  of 
disuse.  There  is  a  distinct  myositis  with  productive  inflammation, 
contraction  and  atrophy,  affecting  particularly  the  biceps  humeri, 
masseter,  erector  spinse,  the  anterior  tibial  group  and  the  hamstrings. 
These  muscles  are  not  necessarily  associated  with  the  involved  joint. 
In  addition  there  is  usually  a  moderate  degree  of  neuritis  or  perineuritis. 

The  general  pathology  is  that  of  a  chronic  infection,  leukocytosis 
with  a  slight  if  any  predominance  of  polymorphonuclear  leukocytes, 
anemia,  emaciation,  trophic  changes  such  as  pigmented  glossy  skin, 
brittle  nails  and  sweating  of  the  palms.  The  lymph  nodes  are  often 
involved,  particularly  those  in  the  region  of  the  infected  joints,  and 
occasionally  the  spleen.  There  is  a  very  frequent  alteration  in  the 
uric  acid  metabolism,  although  never  as  much  as  is  found  in  true 
gout. 

Symptoms. — The  onset  is  of  two  types,  one  fairly  acute,  extending 
over  a  few  days  or  weeks,  occurring  in  young  women,  rarely  at  the 
menopause,  less  frequently  in  males,  with  rapid  serial  involvement 
of  many  joints,  considerable  pain,  slight  rise  in  temperature  and  other 
symptoms  of  a  moderate  infection.  The  second  is  very  gradual, 
extending  over  months  and  years,  occurring  in  old  people,  in  women 
particularly  at  the  time  of  the  menopause.  The  small  joints  of  the 
hand  are  first  involved  with  slight  stiffness,  little  pain,  and  only  become 
generalized  as  in  the  first  type  after  many  months  or  years.  When 
fully  manifest   the   two   types   vary   only  in  severity.      The  joints 


CHRONIC  ARTHRITIS  779 

involved  are,  in  order,  those  of  the  fingers,  hands,  knees,  feet,  ankle, 
wrist,  temporomaxillary,  shoulders,  elbows,  and  hip. 

The  involvement  is  usually  symmetrical.  The  symptoms  may  jump 
from  one  joint  to  another  somewhat  as  in  acute  rheumatic  fever. 
The  pain  is  referred  to  the  joints  involved,  also  to  muscles  affecting 
these  joints,  or  even  isolated.  Sometimes  pain  will  appear  especially 
in  the  shoulder  joint  long  before  the  physical  signs  in  the  joint  can 
be  made  out;  neuralgic  twinges  are  common.  The  character  of  the 
pain  is  dull,  continuous  while  at  rest  with  acute  exacerbation.  It 
occurs  with  the  lowering  of  the  general  condition  by  exposure  to  cold 
and  damp,  insufficient  food,  constipation,  intestinal  fermentation, 
or  intercurrent  infection.  It  is  relieved  by  measures  directed  against 
the  inflammation,  rest,  passive  congestion  and  rarely  by  salicylates. 


Fig.  357. — Arthritis  deformans.     (Musser.) 

It  is  made  worse  by  any  motion  and  unaffected  by  the  time  of  day. 
Voluntary  movement  gradually  becomes  impossible.  The  general 
condition  is  that  of-  any  chronic  infection.  Loss  of  flesh,  strength, 
pallor,  headache,  drowsiness,  etc. 

On  examination  the  joints  vary  somewhat,  as  mentioned  in  the 
pathology.  In  the  hypertrophic  joint  the  skin  has  a  shiny,  bluish 
color  with  prominent  veins,  the  size  of  the  joint  is  considerably 
increased.  The  joint  is  swollen,  globular,  fusiform  or  spindle-shaped, 
with  irregularities  due  to  bony  enlargement  and  distension  by  villous 
masses.  There  may  be  a  slight  increase  in  synovial  fluid,  giving 
fluctuation,  more  often  a  crunching  sensation.  The  extremities  are 
held  in  a  position  to  allow  the  greatest  distension  of  the  joints,  at  first 
in  semiflexion,  later  become  extended  with  the  occurrence  of  luxation. 
In  the  milder  grades  there  is  ulnar  deviation  of  the  fingers  due  to  the 
bony  changes  at  the  bases  of  the  phalanges  (Fig.  357).  The  mobility  is 
limited  at  first  by  pain,  then  by  exudation,  later  by  the  intra-articular 


780  INJURIES  AND   DISEASES  OF  JOINTS 

deformities  and  muscular  contractions.  Sometimes  it  is  increased  in 
an  abnormal  direction  because  of  the  loose  capsule.  On  palpating  the 
joint  there  is  a  crunching  sensation  of  the  villi,  often  crepitus  due  to 
loose  bodies  which  often  can  be  freely  moved  about. 

In  the  sclerotic  variety  the  skin  has  a  more  normal  appearance, 
the  joint  is  normal  in  size,  or  lightly  increased,  the  bony  landmarks 
are  only  slightly  obscured  and  they  are  in  their  normal  relationship. 
The  joint  may  be  held  in  slight  flexion  or  ridgedly  straight.  The 
deformities  of  the  fingers  are  the  same  as  those  previously  mentioned. 
Movement  is  at  first  decreased  by  pain,  later  by  adhesions,  anky- 
losis and  thickening  of  the  capsule.  On  moving  the  joints  there  is  a 
creaking  sensation  rather  than  a  crepitus. 

In  both  joints  the  .r-rays  show  periarticular  swelling,  atrophy  of  the 
cartilage,  erosions  of  the  subchondral  bone,  rarefaction  of  the  spongy 
portion,  the  formation  of  cysts,  thinning  of  the  cortex,  subperiosteal 
swelling,  calcification  and  ossification  of  the  ligaments.  In  the  hyper- 
trophic form  there  are  various  luxations,  pathological  deviations,  dis- 
tortion in  the  shape  of  a  bone  with  osteophytes  and  exostoses,  and 
calcification  of  free  bodies.  In  the  sclerotic  form  there  is  narrowing 
of  the  joint  slits,  fibrous  and  bony  ankylosis.  This  narrowing  of  the 
joint  slits  can  be  determined  by  attempting  to  inject  the  joint  with 
oxygen,  but  this  rather  questionable  procedure  is  rarely  necessary  to 
establish  the  diagnosis,  and  is  not  to  be  recommended. 

General  physical  examination  may  or  may  not  reveal  the  primary 
focus,  and  shows  the  picture  of  chronic  infection  with  enlargement  of 
the  lymph  nodes,  occasionally  of  the  spleen  and  the  blood  picture  of 
infection  with  marked  anemia.  Examination  of  the  metabolism  of 
the  body  shows  a  slight  modification  of  the  uric  acid  metabolism 
and  disturbance  of  the  nitrogen  balance. 

The  course  of  the  disease  is  essentially  chronic  and  progressive,  more 
joints  become  involved,  the  patient  becomes  bedridden,  the  joints 
practically  become  immovable,  the  patient  finally  dies  with  the 
appearance  of  chronic  sepsis. 

Treatment. — Treatment  should  be  undertaken  in  an  institution  with 
facilities  for  specialized  investigation  for  all  parts  of  the  body.  The 
genera]  plan  of  treatment  is  to  remove  the  cause  if  possible,  to  raise  the 
general  resistance  of  the  patient,,  and  secondly  the  local  management 
of  the  joint.  The  cause  is  removed,  after  a  careful  search  of  all  possible 
foci  of  bacteria  by  specially  qualified  men,  by  surgical  means.  If  none 
are  found  after  this  extensive  search,  the  tonsils  are  removed  on  sus- 
picion, in  as  much  as  they  have  been  found  to  be  a  source  of  bacteria 
in  over  half  the  cases  (Billings).  From  the  tissues  removed  the  offend- 
ing organism  is  isolated  if  possible  and  from  it  an  autogenous  vaccine 
prepared.  Mechanical  factors  such  as  faulty  posture,  and  deformities 
as  flat  foot  or  genu  valgum  are  given  appropriate  orthopedic  treatment. 
Foreign  irritating  bodies  occasionally  may  be  removed  surgically 
from  the  joint. 


STILL'S  DISEASE  781 

The  general  treatment  is  to  raise  the  general  body  tone,  to  bring 
about  a  normal  metabolic- balance  and  to  arouse  the  specific  immunity 
against  the  offending  organism.  General  body  tone  is  raised  by  tonic 
treatment  with  fresh  air,  sunlight  and  cheerful  environment,  and  the 
use  of  arsenic,  cod-liver  oil  and  butter  fat.  Metabolism  is  investigated 
and  a  diet  proper  for  the  individual  is  planned,  usually  a  full,  mixed 
diet  but  with  scant  proteids.  Elimination  by  regular  bowel  move- 
ments and  the  drinking  of  large  amounts  of  water  is  fostered, 
with  moderate  physical  rest  sufficient  to  relieve  the  joints  but  not  to 
cause  atrophy.  Glandular  therapy  such  as  thymus  and  thyroid  have 
been  given  empirically  with  possibly  good  results.  Fermentation  in 
the  intestinal  canal  is  combatted  with  large  amounts  of  lactic  acid 
milk. 

To  raise  the  general  specific  immunity  against  the  organism,  auto- 
genous vaccines  are  employed;  made  from  the  joint  tissues,  the  exudate 
from  adjacent  lymph  nodes,  and  from  cultures  made  from  primary 
foci  as  carious  tooth  sockets  or  tonsils.  Antistreptococcus  serum  has 
been  used,  but  danger  from  anaphylaxis  should  prohibit  it. 

Local  Treatment. — Consists  of  rest  for  the  joint  by  the  recumbent 
position  or,  rarely,  by  cast  or  apparatus. 

The  local  resistance  of  the  joint  is  aroused  by  increasing  the  blood 
and  lymph  supply  by  active  congestion  with  the  agency  of  heat  to  the 
skin,  such  as  baking,  hot  water,  electric  light,  and  other  methods;  by 
applying  heat  to  the  interior  of  the  joint  by  the  D'Arsoval  current, 
passive  congestion  after  Bier,  and  by  massage  judiciously  applied. 
Radioactive  agents  such  as  the  ultra-violet  rays,  direct  sunlight,  x-rays, 
high-frequency  current  besides  the  heating  effects  are  supposed  to 
produce  good  results,  but  their  method  of  action  is  as  yet  unknown. 
Irritation  of  the  interior  of  the  joint  by  carbolic  acid,  formalin  and 
iodine  in  glycerine  is  supposed  to  excite  the  structures  to  better  resis- 
tance. The  products  of  inflammation  are  removed  by  compression  of 
the  joint  which  mechanically  forces  the  fluid  to  the  surrounding  tissues, 
and  by  aspiration.  Masses  of  granulation  tissue,  bony  or  cartilaginous 
growths  and  hypertrophied  joint  fringes  are  sometimes  removed  by 
arthrotomy. 

Deformity  should  be  prevented  as  far  as  possible  by  active  and 
passive  motion,  as  soon  as  the  subsidence  of  the  infective  process 
will  permit,  or  later  is  corrected  by  forcible  reduction  by  the 
application  of  corrective  apparatus,  or  by  open  arthrotomy  with 
anthroplasty,  arthrolysis  or  simple  arthrotomy  with  correction  of 
the  deformity. 

Still's  Disease. — Still's  disease  is  a  chronic  progressive  polyarthritis 
similar  to  the  above,  with  rather  marked  febrile  symptoms  occurring 
in  children  usually  under  ten  years  of  age,  characterized  by  severe 
anemia,  leukocytosis,  and  definite  involvement  of  the  lymph  glands 
and  often  of  the  spleen.  It  is  regarded  by  many  as  a  juvenile  form  of 
the  above  condition. 


782  INJURIES  AND  DISEASES  OF  JOINTS 

Chronic  Primary  Hypertrophic  Arthritis  (Chronic  Ulcerative  Arthri- 
tis, Senile  Arthritis,  Morbus  Coxae  Senilis). — Is  a  disease  of  advanced 
life,  involves  one  or  few  joints,  usually  the  larger,  especially  the  hip, 
shoulder,  knee  and  spine;  it  is  asymmetrical  and  causes  little  disturb- 
ance of  the  health.  Its  cause  is  presumed  to  be  the  failure  of  the 
ordinary  reactive  powers  of  the  body  to  withstand  the  normal  trauma 
incident  to  daily  exercise,  although  the  colon  bacillus  is  said  to  have 
been  found  associated  with  this  condition. 

The  pathology  shows  no  ankylosis.  There  is  considerable  lipping 
of  the  edges  of  the  bone  and  cartilage  and  fibrillation  of  the  cartilage 
in  very  old  people.  There  is  bony  overgrowth  with  formation  of  osteo- 
phytes, and  foreign  bodies.  There  is  ulceration  of  the  cartilage  with 
fibrillation  and  often  exposure  of  the  ends  of  the  bone.  The  capsule 
is  moderately  contracted.  The  joint  slits  are  preserved  as  may  be 
seen  by  an  a-ray  plate. 

The  symptoms  are  of  a  local  condition  having  little  effect  on  the 
general  health,  progressive  but  not  disabling.  On  examination  there 
is  stiffness,  grating  of  the  joints  and  the  finding  of  foreign  bodies 
and  inflammation  of  the  ends  of  the  bone. 

Treatment. — The  treatment  is  by  general  tonic  measures,  with 
correction  of  static  deformities,  and  attempts  to  improve  the  local 
resistance  of  the  joint  as  mentioned  in  the  above  section. 

Chronic  Villous  Arthritis. — Chronic  villous  arthritis  is  a  disease  often 
found  in  athletes  especially  in  the  knees  and  is  usually  bilateral.  It  is 
characterized  by  shaggy  formation  of  the  synovial  membrane  covered 
by  low  cylindrical  cuboidal  flat  connective-tissue  cells.  There  is 
scant  fatty  formation  in  the  supporting  stroma.  In  these  fringes  are 
often  found  strips  of  cartilage  formation. 

Its  etiology  is  presumed  to  be  mechanical  irritation  of  the  joint  either 
through  excessive  pressure  between  the  joint  surfaces,  or  more  fre- 
quently because  of  an  increased  leverage  of  motion,  as  is  found  in 
base-ball  players  and  wrestlers. 

The  treatment  is  a  change  of  occupation,  rest  of  the  joint,  massage, 
and  an  increase  of  the  circulation  by  other  means  mentioned  above; 
and  if  necessary  by  the  surgical  removal  of  the  hypertrophied  fringes. 

The  Arthritis  Deformans  of  Children  (Perthes).  This  is  a  condition 
found  in  the  hips  of  children  in  which  there  is  a  melting  away  of  the 
head  of  the  femur,  very  similar  to  the  bony  process  in  tuberculosis, 
but  without  the  discovery  of  the  tubercle  bacillus  in  the  lesion,  or  of 
the  reaction  to  tuberculin. 

The  etiology  is  unknown.  The  symptoms  are  a  disturbance  of  the 
gait  with  little  or  no  pain,  deformity  of  the  joint  with  adduction  because 
of  progressive  trauma.  The  treatment  is  mechanical  support  by  cast; 
the  prognosis  good. 

Syphilitic  Arthritis. — Joint  inflammation  may  develop  as  a  lesion  of 
hereditary  syphilis,  or  as  a  secondary  or  tertiary  symptom  of  the 
acquired  disease. 


TUBERCULOSIS  OF  JOINTS  783 

Hereditary  joint  syphilis  is  generally  an  osteochondritis,  which  may 
give  rise  to  gummatous  degeneration,  separation  of  the  epiphysis, 
and  secondary  involvement  of  the  joint.  The  acquired  disease  may 
be  accompanied  by  a  serous  synovitis  in  the  secondary  stage,  or  give 
rise  in  the  tertiary  period  to  a  gummatous  synovitis  or  epiphysitis 
which  in  its  behavior  closely  resembles  tuberculous  joint  disease. 
Arrest  of  the  growth  of  bone  may  follow  destruction  of  the  epiphysis. 

Symptoms. — In  the  early  secondary  stage  of  acquired  syphilis  the 
joints  may  become  painful  and  swollen  from  the  presence  of  a  serous 
effusion.  This,  however,  quickly  disappears  under  energetic  mercurial 
treatment.  In  the  tertiary  period  an  effusion  may  also  appear,  which 
is  generally  due  to  the  presence  of  some  neighboring  gummatous 
lesion  in  the  bone  or. soft  parts.  Syphilitic  epiphysitis  or  osteochon- 
dritis in  infants  is  characterized  by  enlargement  and  tenderness 
of  the  articular  extremity  of  the  bone.  If  the  disease  progresses,  the 
joint  may  be  invaded  and  the  condition  may  closely  resemble  a  tuber- 
culous arthritis.  Occasionally  it  can  be  distinguished  from  the  tuber- 
culous affection,  however,  by  the  absence  of  muscular  rigidity  and  by 
the  improvement  often  manifested  as  a  result  of  antisyphilitic  treat- 
ment. In  the  more  severe  cases  rapid  destruction  of  the  joint  occurs 
and  suppuration  may  follow,  or  a  painful  and  useless  condition  of  the 
joint  which  has  been  described  as  syphilitic  pseudoparalysis.  In 
acquired  syphilis  the  gummatous  arthritis  also  resembles  the  tubercu- 
lous affection,  and  differential  diagnosis  may  be  impossible.  The 
symptoms  which  would  serve  to  distinguish  a  syphilitic  from  a  tuber- 
culous arthritis  are:  the  presence  of  spontaneous  pain  during  rest  at 
night,  the  absence  of  severe  pain  on  motion  or  manipulation  of  the  joint, 
the  absence  of  muscular  rigidity,  and  the  fact  that  the  tumefaction  of 
the  tissues  and  the  synovial  effusion  if  present,  vary  considerably  in 
extent  from  time  to  time  even  without  treatment.  In  most  of  the 
reported  cases  the  knee-joint  has  been  the  one  chiefly  involved. 

Treatment. — Syphilitic  joint  disease  should  be  treated  by  large  doses 
of  salvarsan  and  mercury  in  the  secondary  stage,  with  the  addition  of 
potassium  iodide  in  the  later  stages. 

Tuberculosis  of  Joints. — Etiology. — The  predisposing  cause  is  that 
of  tuberculosis  in  general.  Ill  health  from  improper  nourishment 
and  from  disease  such  as  measles  and  scarlet  fever  and  possibly  from 
family  susceptibility.  Contagion  from  a  tuberculous  environment, 
either  by  inhalation  or  through  the  food  is  by  far  the  most  important 
element.  The  exciting  factor  is  the  tubercle  bacillus,  usually  the  human 
type  but  occasionally  the  bovine.  The  portals  of  entrance  are  most 
often  the  intestinal  mucosa,  with  subsequent  caseation  in  the  mesenteric 
lymph  nodes  and  the  liberation  in  the  blood  of  the  bacilli,  which  find 
their  resting  place  in  the  end  vessels  of  the  epiphyseal  or  subchondral 
bone  of  the  joints  in  the  young,  and  in  the  lungs  in  adults.  Other 
less  frequent  portals  of  entry  are  the  lungs,  the  nose,  the  pharynx, 
faucial  and  lingual  tonsils,  the  teeth  and  possibly  directly  through  the 


784  INJURIES  AND  DISEASES  OF  JOINTS 

skin.  Tuberculosis  is  the  most  frequent  cause  of  joint  disease.  It  is 
commonest  in  children  but  may  occur  at  any  age.  Whitman  says 
that  out  of  5401  cases  of  tuberculosis  of  the  joints  seven-eighths 
occurred  in  subjects  under  fourteen  years  of  age.  The  joints  most 
commonly  affected  are  in  the  order  of  frequency — the  spine,  hip,  knee, 
ankle,  elbow,  shoulder,  and  wrist.  The  disease  is  usually  monarticular 
but  may  involve  more  than  one  joint. 

Pathology. — The  pathology  is  that  of  tubercle  formation  primarily 
in  the  spongy  bone  of  the  epiphysis  and  spreading  secondarily  to  the 
joint.  Nichols,  after  a  careful  microscopic  examination  of  the  material 
from  more  than  120  tuberculous  joints,  failed  to  find  a  single  instance 
in  which  there  was  reason  to  believe  that  the  disease  primarily  occurred 
in  the  synovial  membrane,  while  Clarke  and  others  have  demonstrated 
primary  synovial  tuberculosis  in  a  few  adult  cases. 

The  process  begins  by  a  deposit  of  tubercle  bacilli  in  the  end  vessels 
of  the  subchondral  bone.  This  produces  a  typical  tubercle  with 
caseous  centre,  giant  cells  and  surrounding  connective  tissue.  The 
process  may  be  here  arrested  but  in  most  cases  the  area  of  necrosis 
and  cheesy  degeneration  gradually  extends  peripherally,  and  finally 
ruptures  into  the  joint,  often  by  a  minute  opening  through  the  articular 
cartilage.  As  soon  as  the  tuberculous  material  gains  access  to  the 
synovial  membrane  there  occurs  an  acute  miliary  tuberculosis  of  that 
tissue,  with  congestion,  exudation,  necrosis  and  formation  of  granula- 
tion tissue  involving  the  synovia,  cartilages  and  bones  which  have  a  com- 
mon synovial  sac.  As  the  process  advances  the  cartilages  disappear,  the 
bones  become  exposed  and  eroded,  the  extra-articular  fibrous  tissues 
become  edematous  and  softened,  the  ligaments  relaxed,  and  spon- 
taneous dislocation  may  occur.  The  resulting  lesion  as  in  non-tuber- 
culous inflammations,  is  first  a  synovial  type  with  a  great  increase 
of  synovial  fluid,  secondly  the  "pulpy"  type,  with  fungating  masses 
of  granulation  tuberculous  tissue,  and  thirdly — the  dry  type,  a  sclerotic 
process  leading  to  fairly  stiff  fibrous  or  bony  ankylosis. 

If  the  joint  capsule  ruptures,  the  tuberculous  material  finds  its  way 
into  the  soft  tissues,  where  it  slowly  extends  in  the  direction  of  least 
resistance  along  the  fascial  plane,  until  it  may  finally  rupture  on  the 
surface.  This  lesion  of  the  soft  tissues  is  spoken  of  as  "  cold  abscess," 
and  is  unaccompanied  by  pain,  tenderness,  redness  of  the  skin,  or  other 
evidences  of  inflammation.  The  fluid  contents  of  a  cold  abscess 
consist  of  necrosed  and  softened  particles  of  bone  and  cartilage,  frag- 
ments of  degenerated  soft  tissues,  caseous  material,  polymorphonuclear 
leukocytes,  a  high  proportion  of  lymphocytes,  tubercle  bacilli  in  small 
numbers,  an  occasional  rice  body  and  serum.  It  is  called  tuberculous 
pus.  These  cold  abscesses  may  reach  a  large  size  and  rupture  at  a 
considerable  distance  from  the  original  bone  focus,  which  may  be 
comparatively  small  in  extent.  When  they  rupture  there  forms  a 
sinus  lined  by  granulation  tissue  leading  down  to  the  bony  focus. 
Without   secondary    infection   these   heal   as   does   any   tuberculous 


TUBERCULOSIS  OF  JOINTS  785 

process,  but  when  so  infected  the  healing  is  greatly  prolonged  and  leads 
to  long  continued  pus  formation,  and  secondary  waxy  degeneration 
in  the  liver  and  kidneys. 

The  termination  of  the  tuberculous  process,  of  whatever  type, 
may  be  by  death,  or  healing  with  absorption  of  the  inflammatory 
product,  death  of  the  tubercle  bacilli,  cicatrization  of  the  destroyed 
areas  with  possible  calcification,  and  where  the  surface  of  the  joint  has 
been  eroded,  fibrous  ankylosis,  or  if  deeper,  bony  ankylosis.  Carti- 
laginous ankylosis  is  a  pathological  curiosity.  If  the  joint  so  heals  the 
synovial  membrane  may  be  partly  preserved.  When  one-quarter  to  one- 
half  remains,  mobility  of  the  joint  may  be  expected.  Otherwise  there 
will  be  stiffness,  atrophy  of  the  muscles  about  the  joint  and  in  the 
bones  entering  into  its  structure,  of  the  same  type  as  that  found  in 
other  chronic  joint  inflammations,  but  of  much  greater  degree. 

Symptoms. — The  onset  is  nearly  always  gradual  with  the  rare  but 
conspicuous  exception  of  the  acute  type  already  mentioned.  Symp- 
toms of  the  onset  are  pain  and  disturbance  of  function  causing  protect- 
ing movements  and  attitudes  in  the  use  of  the  joints.  Rarely,  swelling 
may  be  the  first  symptom,  especially  in  adults  and  in  spinal  tuberculosis 
of  the  lower  lumbar  region. 

The  symptoms  become  fully  manifest  after  a  very  variable  period 
from  weeks  to  many  months.  Chief  of  these  is  pain,  referred  to  the 
diseased  joint,  or  by  irritation  of  nerve  trunks  to  the  areas  supplied 
by  them,  the  character  is  dull,  continuous  with  sharp  exacerbations. 
It  is  worse  at  night  causing  night  cries  and  increased  by  any  jarring 
or  movements,  it  is  relieved  only  by  fixation  and  relief  of  pressure 
from  the  joint  surfaces.  Function  of  the  joint  is  completely  or  partially 
lost  because  of  the  limitation  of  motion  by  mechanical  deformities 
inside  the  joint,  and  secondly  because  of  the  marked  muscular  spasm 
holding  the  joint  in  the  most  comfortable  position,  which  makes  it 
almost  impossible  to  estimate  the  range  of  motion  without  an  anes- 
thetic. The  appearance  of  the  joint  is  altered,  both  by  the  occurrence 
of  a  fusiform  swelling  due  to  effusion  or  the  presence  of  granulation 
tissue,  and  to  an  abnormal  pallor  of  the  skin  (tumor  albus). 

The  deformity  of  the  extremity  is  caused  by  the  joint  being  held 
in  the  position  allowing  the  greatest  distension  of  the  capsule,  usually 
in  mid-flexion,  by  subluxation  of  the  joint  and  by  marked  atrophy 
of  the  muscle  concerned,  which  is  out  of  proportion  to  the  atrophy  of 
disuse. 

The  general  symptoms  are  those  of  any  toxemia  but  perhaps  less 
marked  than  with  similar  lesions  caused  by  other  agencies. 

The  physical  examination  shows  a  wasted  extremity,  limited  in  active 
and  passive  motion,  with  a  whitish  swollen  joint  whose  bony  outlines 
are  obliterated  or  obscured,  giving  the  signs  of  fluid  or  a  boggy  sen- 
sation to  the  examining  hand.  Tenderness  is  general  over  the  joint 
and  more  marked  over  the  bone  which  is  most  involved.  It  is 
obtained  by  both  direct  and  indirect  pressure  through  the  shaft  of 
50 


780 


INJURIES  AND  DISEASES  OF  JOINTS 


the  bone.   Muscle  spasm  is  detected  by  comparing  the  range  of  motion 
before  and  during  an  anesthetic. 

Clinical  course  without  treatment  is  progressively  downward  with 
the  formation  of  cold  abscesses,  sinuses,  waxy  degeneration,  and  death. 
Under  ideal  treatment  the  general  and  local  conditions  improve  in 
nearly  all  cases,  so  that  it  may  be  said  that  the  prognosis  depends 
in  great  measure  on  the  financial  ability  to  secure  transportation  to 
proper  environment  and  to  obtain  the  proper  amount  of  local  treat- 


Fig.  358. — Acute  tuberculous  arthritis  of  the  knee.     (Whitman.) 


ment.  Under  older  conditions  the  mortality  was  36  per  cent,  in 
the  first  decade  of  life,  40  per  cent,  in  the  second  and  in  the  third 
72  per  cent. 

Treatment. —  General  Treatment. — This  should  consist  in  measures 
to  raise  the  general  resistance  of  the  patient,  to  combat  the  spread 
of  infection,  and  to  overcome  the  effects  of  toxemia.  The  regular  diet 
should  be  of  high  caloric  value.  To  this  should  be  added  extra  diet 
rich  in  fat,  as  cream,  cod-liver  oil,  or  an  excess  of  butter.  Sleeping 
out  of  doors,  the  constant  exposure  of  the  body  to  fresh  air  and  sun- 
shine, moderate  exercise  when  possible,  and  other  hygienic  measures 


TUBERCULOSIS  OF  JOINTS  787 

are  indicated.  Tuberculin  treatment  has  been  advised,  but  its  effect 
is  doubtful. 

Local  Treatment — The  removal  of  a  small  localized  tuberculous  bone 
focus,  before  rupture  into  the  joint,  is  an  ideal  procedure,  but  the 
opportunity  for  this  is  rare.  Where  the  joint  is  already  involved,  the 
treatment  should  be  by  fixation  and  traction.  The  former  to  over- 
come untoward  effects  of  functional  use,  and  the  latter  to  remove 
pressure  from  the  inflamed  joint  surfaces.  The  local  resistance  of  the 
joint  may  sometimes  be  increased  by  active  or  passive  hyperemia. 
The  former  may  be  brought  about  by  heat,  massage,  counter-irritation, 
and  the  high  frequency  currents.  The  latter  by  constriction,  or 
Bier's  method  of  passive  hyperemia.  Heliotherapy  as  practiced  by 
Rolier  in  the  Swiss  Alps  has  proved  of  the  greatest  value  in  a  number 
of  apparently  hopeless  cases.  Whether  the  result  is  due  to  the  bacteri- 
cidal action  of  the  direct  rays  of  the  sun,  or  to  the  raising  of  the  gen- 
eral resistance  of  the  patient  by  the  active  out-door  life,  is  impossible 
to  determine.  Probably  both  of  these  factors  play  a  part  in  the  pro- 
cess.  It  has  been  suggested  that  the  joint  resistance  may  be  further 
raised,  and  possibly  bacteria  destroyed,  by  the  injection  of  iodoform 
and  glycerine,  dilute  solutions  of  formalin,  or  other  slightly  irritating 
antiseptic  agents. 

Operative  Treatment. — In  general  it  may  be  stated  that  operative 
treatment  is  indicated  in  all  cases  where  the  primary  bone  focus  can 
be  removed  before  the  joint  has  been  invaded.  In  general,  operative 
treatment  is  earlier  indicated  in  adults,  and  in  lesions  of  the  lower 
extremities;  conservative  treatment  being  indicated  in  children,  and 
in  the  joints  of  the  upper  extremities,  where  recovery  with  motion  may 
be  expected.  It  is  a  general  principle  in  tuberculous  joint  disease,  that 
if  firm  ankylosis  can  be  established,  the  disease  will  become  quiescent 
or  disappear.  For  this  reason,  operation  upon  the  spine  and  joints  of 
the  lower  extremity  with  a  view  to  bringing  about  ankylosis  are  to  be 
advised  in  cases  which  have  resisted  conservative  measures.  In  chil- 
dren arthrotomy  with  removal  of  the  diseased  cartilage,  followed  by 
fixation,  is  to  be  advised,  for  the  reason  that  the  more  formal  excisions 
are  apt  to  interfere  with  the  growth  of  the  bone  from  injury  to  the 
epiphysis.  In  adults  formal  excisions  are  indicated.  The  details  of 
these  operative  procedures  will  be  mentioned  under  treatment  of  the 
various  joints. 

Amputation  is  indicated  to  preserve  life  and  where  as  in  many 
cases  of  carpal  infection  erasion  or  excision  promises  an  unsatisfac- 
tory, or  extremely  prolonged  convalescence  with  an  uncertain  result. 
Operations  devised  to  splint  the  infected  joint,  as  in  the  spine,  will  be 
mentioned  under  that  heading. 

The  treatment  of  cold  abscesses  is  conservative  until  rupture  is 
imminent,  or  until  pressure  causes  symptoms.  They  are  opened  under 
absolute  aseptic  precautions  by  means  of  a  large  trocar  and  canula 
with   aspirating   apparatus,    or   through    small    incisions   which   are 


788 


INJURIES  AND  DISEASES  OF  JOINTS 


immediately  closed  without  drainage.  The  former  is  preferable  where 
practicable,  but  with  large  cheesy  masses  in  the  cavity  the  second 
may  be  indicated.  Secondary  infection  of  a  cold  abscess  converts  a 
self  healing  process  into  an  almost  interminable  draining  wound. 

In  the  treatment  of  sinuses,  drainage  should  be  avoided  as  far  as 
possible  and  the  sinus  sterilized  with  cautious  application  of  pure 
phenol  on  a  probe  or  injected  through  a  small  catheter  by  a  finely 
graduated    syringe.     Emil    Beck   observed   that   sinuses   filled   with 

bismuth  subnitrate  mixture  for  radio- 
graphic purposes  healed  spontaneously, 
and  working  upon  this  basis  he  has  pre- 
pared a  mixture  consisting  of  vaseline, 
bismuth  subnitrate,  white  wax,  and  soft 
paraffin.  This  is  fluidefied  by  heat  and 
injected  into  the  sinus  up  to  the  point 
of  discomfort.  The  opening  is  next  closed 
until  the  mixture  has  hardened  and  then 
covered  by  sterile  dressing.  After  several 
hours  or  clays  small  bits  of  the  mixture 
may  be  discharged,  but  occasionally  the 
whole  mass  remains.  The  results  are  in 
the  main  good. 

TUBERCULOUS    DISEASE  OF  SPECIAL 
JOINTS. 

Pott's  Disease.  —  Pott's  disease,  or 
tuberculous  spondylitis,  is  a  tuberculous 
disease  of  the  vertebral  bodies.  It  is 
most  common  before  the  twentieth  year, 
GO  per  cent,  of  the  cases  occurring  in  the 
first  decade  of  life.  The  lower  dorsal 
region  is  most  frequently  affected,  al- 
though it  may  occur  in  any  region.  The 
disease  usually  begins  in  the  body  of 
one  vertebral  segment  while  the  spinous 
processes  are  preserved.  The  bacilli 
lodge  in  the  areas  occupied  by  the 
terminal  vessels,  either  (1)  in  the  centre 
of  the  body,  (2)  near  the  epiphysis  going  on  to  the  adjoining 
vertebra,  or  (3)  superficially  in  the  area  supplied  by  the  inter- 
costal arteries.  It  generally  ruptures  anteriorly,  and  may  extend 
upward  or  downward  beneath  the  prevertebral  ligament  and 
involve  secondarily  the  bodies  of  other  vertebra?.  The  intervertebral 
cartilage  may  become  diseased  in  the  later  stages  of  the  process.  As 
a  result  of  a  caving  in  of  the  vertebral  bodies  which  support  the 
weight  of  the  trunk,  an  angular  curvature  of  the  spine  occurs,  with 


Fig.  359. — Psoas  abscess. 


TUBERCULOUS  DISEASE  OF  SPECIAL  JOINTS 


789 


the  formation  of  a  projecting  knuckle  of  bone  behind  (Fig.  360). 
Under  favorable  conditions  bony  ankylosis  and  recovery  may  take 
place.  In  other  cases  a  cold  abscess  forms,  which,  if  the  disease  is 
located  in  the  cervical  region,  may  point  in  the  pharynx,  retropharyn- 
geal abscess,  or  at  the  side  of  the  neck;  if  lower  down,  in  the  intercostal 
spaces  near  the  spine,  in  the  lumbar  region,  lumbar  abscess,  or,  by 
entering  the  sheath  of  the  psoas  muscle,  in  the  groin  or  thigh,  psoas 
abscess  (Fig.  359) .  The  abscess  rarely  ruptures  into  the  pleural  cavity, 
lung,  or  one  of  the  abdominal  organs.  In  many  cases  the  abscess  is 
not  recognized  during  life.     Pressure  on  the  spinal  cord,  causing  more 


Fig.  360. — Pott's  disease.     Spinal  column  divided  longitudinally. 


or  less  complete  paraplegia,  may  be  due  to  bony  deformity,  but  is  com- 
monly the  result  of  a  tuberculous  spinal  pachymeningitis,  or  edema  of 
the  meninges  and  cord. 

Symptoms. — The  prodromal  symptoms  are  those  of  general  toxemia 
persisting  for  a  few  weeks  or  several  months  without  any  focal  symp- 
toms. The  first  symptom  noticed  may  be  the  external  appearance  of  a 
cold  abscess.  The  onset,  however,  is  usually  of  gradual  pain,  spinal 
rigidity,  kyphosis,  symptoms  of  first  irritation  and  then  paralysis  of 
the  spinal  nerves,  abscess  formation  and  rupture,  together  with  signs 
of  a  general  toxemia.  The  pain  is  located  at  the  site  of  disease  or  is 
referred  by  irritation  of  emerging  spinal  nerves  to  the  corresponding 


790 


INJURIES  AND  DISEASES  OF  JOINTS 


skin  area,  usually  the  abdomen.  The  character  is  dull,  continuous 
with  sharp  exacerbations,  especially  at  night,  causing  night  cries.  It 
is  made  worse  by  any  mechanical  irritation,  such  as  pressure  during 
examination,  or  sudden  movement  or  jars.  Later  in  the  disease 
there  appear  paralytic  disturbances,  paresthesia  and  anesthesia, 
together  with  motor  paralysis  because  of  nerve  destruction  by  the 
lesion.  Spinal  rigidity  is  shown  by  the  peculiar  cautious  gait  and  by 
the  protective  posture  assumed  in  attempting  to  pick  up  objects  from 
the  floor  or  otherwise  use  the  trunk  (Fig.  361).  On  examination 
this  is  shown  by  palpating  the  firm  contracted  erector  spina1, 
and    by    noting    the    lack  of   anteroposterior    and    lateral    mobility 


Fig.  361. — Lumbar  disease.  The 
manner  of  picking  up  an  object. 
(Whitman.) 


I^ig.  362. — Plaster  jacket. 


of  the  spine  by  placing  child  on  the  abdomen,  and  with  the  lower 
extremities  as  levers  swinging  the  hips  upward,  downward  and  laterally. 

Deformity  is  the  result  of  the  backward  bowing  of  the  spinous 
processes  as  the  bodies  of  the  vertebra?  fall  together  anteriorly.  These 
are  usually  single  but  may  be  multiple  and  occur  as  pointed  knuckles 
or  more  rounded  eminences  with  the  spines  of  several  vertebrae  very 
prominent.  Lateral  deformity  is  not  common  and  occurs  in  the  early 
advancing  cases  because  of  the  asymmetric  destruction  of  the  bodies. 
Compensatory  lordosis  occurs  above  and  below  the  lesion  together 
with  deformity  of  the  pelvis. 

Abscesses  and  fistula?  depend  on  the  line  of  least  resistance  along 
the  spinal  muscles  as  mentioned  under  pathology. 


TUBERCULOUS  DISEASE  OF  SPECIAL  JOINTS  791 

Treatment. —  General  treatment  is  carried  out  as  in  tuberculosis  in 
any  form  preferably  in  an  institution. 

Local  treatment  aims  to  remove  the  pressure  of  the  superimposed 
weight  from  the  diseased  vertebra,  to  prevent  motion  of  the  spine  in 
any  direction  and  to  prevent  or  correct  deformity.  All  three  of  these 
objects  are  attained  in  varying  degree  by  each  of  the  methods  of 
mechanical  treatment.  The  relief  from  the  superimposed  weight 
is  best  accomplished  by  the  recumbent  position  which  should  be 
assumed  in  all  very  early  .or  advanced  cases,  during  abscess  formation, 
when  apparatus  becomes  intolerable  and  when  there  is  evidence  of 
great  softening  of  the  vertebral  body  as  indicated  by  the  yielding  of 
the  spinal  deformity  when  pressure  is  made  over  it.  Pressure  is  further 
relieved  by  continued  traction  on  the  spinal  column  while  recumbent, 
or  by  so  constructing  braces  and  plaster  casts  that  they  hold  firmly 
the  pelvis  at  their  base  and  lift  the  upper  trunk  under  the  arms,  and  in 
lesions  above  the  eighth  dorsal  vertebra  by  a  jury  mast  supporting 
the  head. 


Fig.  363. — The  Bradford  frame  bent  to  assure  overextension  of  the  spine.     (Whitman.) 

Fixation  of  the  trunk  is  attained  by  a  snugly  fitting  plaster  cast 
(Fig.  362),  by  strapping  securely  on  a  Bradford  frame  (Fig.  363),  and 
by  the  use  of  a  system  of  rigid  braces.  The  Taylor  brace  directly 
combats  the  tendency  to  kyphosis  by  pressure  over  the  knuckle  and 
counter  pressure  against  the  pelvis  and  shoulder  girdle  (Fig.  364). 

The  prevention  and  correction  of  deformities  is  daily  assuming 
greater  importance.  Because  of  the  danger  of  rupturing  tissues  loaded 
with  tuberculous  material,  and  injury  to  the  vessels  and  nervous  tissues, 
the  method  of  Calot  of  forcibly  reducing  the  deformity  under  an  anes- 
thetic has  given  way  to  slower  but  none  the  less  complete  methods. 
The  mechanics  of  all  the  methods  are  the  same;  pressure  of  as  high 
degree  possible  on  the  apex  of  the  deformity  with  more  or  less  counter 
pressure  on  the  shoulders  and  pelvis,  together  with  more  or  less  trac- 
tion from  above  and  below  to  elongate  the  spine.  Goldthwaite 
accomplishes  this  with  a  special  apparatus  for  pressing  forward  on 
either  side  of  the  gibbus  by  heavily  padded  and  shaped  parallel  wires, 
accompanied  by  traction  on  the  head  and  lower  limbs.  Extension  of 
the  spine  is  accomplished  by  the  weight  of  the  supine  unsupported 
upper  and  lower  portions  of  the  body.     Whitman  bends  a  Bradford 


792 


INJURIES  AND  DISEASES  OF  JOINTS 


frame  to  the  proper  angle  using  the  canvas  sheet  to  give  the  pressure 
on  the  gibbus.  Tubby  uses  a  curved  split  pillow  with  room  for  the 
most  prominent  skin  surface  to  escape  pressure.  Bradford  follows  the 
same  principle  by  a  pillow  in  his  frame  and  pressing  on  the  gibbus. 
Tunstall  Taylor  uses  a  device  called  a  Kyphotone  to  forcibly  extend 
the  spine  while  pressure  is  being  exerted  on  the  gibbus,  and  when  the 
deformity  is  sufficiently  corrected  to  apply  a  plaster  cast  to  preserve 
the  new  shape.    In  a  still  more  gradual  way  the  plaster  cast  and  espe- 


Fig.   3G4. — The  Taylor  brace  and  head  support  applied  for  disease  of  the  upper  dorsa 

region.     (Whitman.) 


cially  the  Taylor  brace  accomplish  the   same   result  in   ambulatory 
patients. 

The  operative  methods  for  accomplishing  the  above  principles  aim 
at  developing  a  bony  splint  to  support  the  spine  at  the  diseased  area. 
Albee  accomplishes  this  by  splitting  sagitally  the  spines  of  the  diseased 
vertebra?  together  with  the  two  or  three  above  and  below,  and  in  this 
cleft  inserting  and  fastening  a  splint  about  three  millimeters  thick 
and  two  centimeters  wide  shaved  from  the  tibia.  This  graft  grows 
and  forms  a  solid  bony  column  for  the  support  of  the  body  weight. 


TUBERCULOUS  DISEASE  OF  SPECIAL  JOIXTS 


793 


Done  in  cases  not  far  advanced  it  shortens  the  treatment  greatly  and 
thus  far  has  given  permanent  results  (Fig.  365). 

Another  and  equally  successful  method  of  accomplishing  this  result 
is  the  procedure  of  Hibbs.  He  removes  the  periosteum  from  several 
spinous  processes  and  the  corresponding  laminae,  partly  divides  the 
processes,  and  by  fracturing  them  near  their  bases  and  forcing  them 


Fig. 


365. — X-ray  photograph  of  transplanted  bone  splint  in  the  spines  of  the  vertebra. 
G-G',  bone  graft;   T,  focus  of  disease  in  vertebra. 


downward  in  contact  with  the  denuded  lamina?,  brings  about  a  bony 
anchylosis  of  the  diseased  area. 

Cold  abscesses  and  sinuses  have  been  considered  above.  Paralysis 
is  best  avoided  by  the  recumbent  position  with  the  first  symptom. 
Forcible  reduction  is  occasionally  followed  by  a  slight  increase  of 
paralysis  but  is  generally  later  followed  by  rapid  improvement. 


794 


INJURIES  AND  DISEASES  OF  JOINTS 


The  operative  removal  of  tuberculous  vertebral  sequestra  is  seldom 
undertaken  because  of  the  good  results  to  be  expected  of  conservative 
treatment  and  the  uncertain  results  of  operation. 

Tuberculosis  of  the  Hip. — Hip  disease,  morbus  coxae,  or  tuberculous 
arthritis  of  the  hip-joint,  is  essentially  a  disease  of  childhood  and  youth. 
206  out  of  241  cases  reported  in  Alfer's  table  occurred  before  the 
twentieth  year.  The  disease  may  begin  in  the  spongy  tissue  of  the 
head  of  the  bone  near  the  upper  epiphyseal  line,  less  often  in  the  acetab- 
ulum.    In  either  event  the  synovial  membrane  is  quickly  involved, 

and  there  is  extensive  destruction 
of  the  articular  cartilages  and  the 
bone,  with  osteophytic  growths, 
masses  of  granulation  tissue,  relax- 
ation of  the  ligaments  and  sponta- 
neous dislocation. 

Symptoms. — A  slight  limp  is  gene- 
rally the  first  symptom,  with  some 
pain  and  stiffness  of  the  joint  after 
an  unusual  amount  of  walking. 
The  pain  is  often  insignificant  and 
may  be  referred  to  the  region  of  the 
knee.  Sudden  paroxymals  pains 
and  "  night  cries"  are  frequent  as  the 
disease  advances.  When  an  effusion 
occurs  in  the  joint  the  limb  is 
slightly  flexed,  abducted,  and  rota- 
ted outward.  There  is  slight  fulness 
in  the  upper  part  of  Scarpa's  trian- 
gle, and  a  partial  obliteration  of  the 
gluteal  fold.  Tenderness  exists  about 
the  hip,  and  forcing  the  head  of 
the  bone  against  the  acetabulum  by 
striking  the  trochanter  or  knee  is 
painful.  There  is  noticeable  limi- 
tation of  motion  with  well-marked 
muscular  rigidity.  This  is  occa- 
sionally spoken  of  as  the  stage  of 
apparent  lengthening.  As  the  disease  progresses  there  is  considerable 
deformity,  due  to  flexion  of  the  limb  and  tilting  of  the  pelvis.  Walking 
becomes  more  and  more  painful  and  the  patient  finally  becomes  bed- 
ridden. Atrophy  of  the  muscles  of  the  thigh  and  leg  is  always  present 
at  this  stage  of  the  disease,  and  abscesses  may  appear.  Together 
with  these  local  symptoms  there  are  afternoon  fever,  loss  of  flesh  and 
strength,  and  general  bodily  weakness.  When  the  head  of  the  bone  is 
destroyed  or  the  rim  of  the  acetabulum  has  broken  down,  upward 
traction  by  the  muscles  results  in  luxation  of  the  head  or  neck  of  the 
bone,  and  the  formation  of  an  abscess  in  the  soft  tissues.     The  position 


Fig.  366. — Thomas  splint  applied  with 
patten  and  crutches. 


TUBERCULOUS  DISEASE  OF  SPECIAL  JOINTS  795 

of  the  limb  is  then  changed  to  one  of  flexion,  adduction,  and  internal 
rotation.  Bony  ankylosis  and  recovery  may  take  place  at  any  period 
of  the  disease,  but  extension  of  the  disease  to  other  organs,  and  general 
ill  health  from  prolonged  suppuration  and  suffering,  are  apt  to  bring 
about  a  fatal  termination. 

Treatment. —  General  treatment  has  already  been  considered. 

Local  Treatment. — In  the  early  stages  with  the  patient  recumbent 
the  joint  surfaces  are  separated  by  traction  of  the  thigh  in  moderate 
abduction  and  flexion  (Fig.  366)  which  gives  better  results  than  simple 
fixation.  With  the  subsidence  of  acute  symptoms,  fixation  in  this 
position  is  accomplished  by  plaster  spica  or  Thomas  splint  (Fig.  366) 
with  a  high-soled  shoe  on  the  sound  foot.  The  favorable  effect  of 
traction  by  the  Taylor  or  Sayre  traction  splint,  which  allows  walking 
without  crutches,  is  recognized  by  most  surgeons.  Whitman  has 
devised  a  splint  which  insures  both  fixation  and  traction  (Fig.  368). 


Fig.  367. — A  method  of  reducing  flexion  in  hip  disease.  The  brace  is  adjusted  to 
the  angle  of  deformity,  and  in  addition  to  the  direct  traction  of  the  apparatus  weights 
are  attached  to  the  brace  itself.  In  the  illustration  counter-traction,  by  means  of 
perineal  bands  attached  to  the  head  of  the  bed,  is  shown.     (Whitman.) 


For  a  description  of  these  splints  and  the  method  of  their  application, 
the  reader  is  referred  to  standard  works  on  orthopedic  surgery. 

If  conservative  treatment  fails  to  arrest  the  disease,  or  if  life  is 
threatened  by  persistent  suppuration,  excision  or  amputation  is  as  a 
last  resort  to  be  recommended. 

Excision  of  the  Hip. — The  patient  is  anesthetized  and  placed  on  the 
sound  side.  An  incision  is  made  from  a  point  two  inches  above  the 
tip  of  the  great  trochanter  to  two  or  three  inches  below,  parallel  with 
the  shaft.  The  tissues  are  divided  down  to  the  periosteum,  the 
muscular  attachments  to  the  tuberosity  are  separated  with  a  thin 
layer  of  cartilage  or  bone  and  well  retracted,  the  joint  capsule  opened, 
and  the  head  of  the  bone  dislocated.  The  diseased  portion  is  then 
removed  with  the  saw  or  bone-forceps,  the  acetabular  disease  removed 
with  a  Volkmann  spoon,  the  joint  cavity  thoroughly  swabbed  with 
pure  carbolic  acid  or  a  solution  of  formalin,  and  the  wound  closed  tight 
unless  there  is  secondary  infection.     Extra  capsular  resection  (Barden- 


79C> 


INJURIES  AND  DISEASES  OF  JOINTS 


heuer)  in  which  there  is  removal  of  acetabulum  aud  upper  femur  en 
masse,  has  been  used  for  extensive  disease  of  the  acetabulum. 

Amputation  at  the  hip-joint  is  indicated  in  hopelessly  diseased 
limbs.  The  final  results  of  hip  disease  vary  greatly,  depending  upon 
the    opportunities    for    early    efficient   treatment.     The   death   rate 

reported  by  Sayre  in  212  private  cases  was 
only  a  little  over  2  per  cent.  The  hospital 
death  rate  is  from  12  to  30  per  cent. 
The  functional  result  of  the  cured  cases 
treated  conservatively  depends  largely 
upon  the  amount  of  care  which  is  exer- 
cised in  the  treatment. 

Tuberculous  Arthritis  of  the  Knee.— 
Although  knee-joint  tuberculosis  is  more 
common  in  childhood,  yet  a  fair  propor- 
tion of  the  cases  (more  than  one-third) 
develop  in  individuals  over  twenty  years 
of  age.  The  disease  may  begin  in  any  of 
the  bones  which  enter  into  the  formation 
of  the  joint,  or  possibly  in  the  synovial 
membrane.  Epiphysitis  of  the  tibia  is, 
however,  the  most  frequent  primary 
focus,  and  disease  of  the  femur  next. 

Symptoms. — In  this,  as  in  hip  disease, 
early  lameness,  stiffness,  and  pain  in  the 
joint  constitutes  the  first  symptoms. 
Night  cries  are  less  frequent,  but  tender- 
ness is  more  marked.  There  are  usually 
early  tenderness  and  thickening  of  the 
articular  extremity  of  the  tibia  or  femur. 
An  early  synovial  effusion  may  be  the 
first  symptom,  but  this  does  not  neces- 
sarily argue  in  favor  of  a  primary  syno- 
vial focus,  for  it  occurs  in  painless  epi- 
physeal foci  of  disease,  before  the  joint 
is  infected.  When  the  joint  is  finally 
invaded,  there  is  the  gradual  develop- 
ment of  a  boggy  fusiform  swelling,  with 
muscular  rigidity,  fixation  of  the  limb 
in  a  partly  flexed  position,  and  atrophy 
of  the  muscles  of  the  thigh  and  leg  (Fig. 
369).  The  lameness  becomes  more  marked,  flexion  increases,  and 
general  deterioration  of  the  health  ensues.  As  the  disease  ad- 
vances, the  ligaments  become  softened  and  relaxed,  and  a  sponta- 
neous backward  subluxation  with  rotation  occurs,  which,  with  the 
oval  fusiform  swelling,  gives  to  the  leg  a  characteristic  appearance. 
Abscess  formation  is  less  frequent  than  in  hip  disease. 


Fig.  368.— Whitman's  splint. 


TUBERCULOUS   DISEASE  OF  SPECIAL  JOINTS 


-'.»; 


Treatment. — In  the  early  stages  of  the  disease  it  may  he  possible  to 
locate  and  remove  the  bone  focus  before  it  has  broken  through  the 
cartilage  and  infected  the  joint.  Where  the  joint  is  involved  the  treat- 
ment should  be  conservative.  Rest  in  bed  with  traction  by  means  of  a 
weight  and  pulley  will  relieve  pain,  correct  deformity,  and  overcome 
muscular  spasm.  The  direction  of  the  traction  is  in  the  direction 
of  the  leg  as  held  in  it-  deformed  position  and  not  in  the  direction  of 
the  thigh.  When  this  is  accomplished  the  joint  should  be  fixed  with 
a  plaster-of-Paris  cast  extending  from  the  groin  to  the  ankle,  or  by  a 
Thomas  knee-splint   (Fig.  .'!7n  .     A   high-soled    shoe  should  be  pro- 


^q: 


Fig.  369. — Synovial  tu 


the  knee. 


Fig.  370.— The  Thomas 
knee- splint. 


vided  for  the  sound  foot  and  the  diseased  knee  protected  by  the  use 
of  crutches;  or  if  the  upright  bars  of  the  Thomas  splint  extend  below 
the  foot  and  are  joined  by  a  metal  plate,  the  patient  may  discard  the 
crutches  and  walk  upon  the  splint. 

Operative  treatment  is  indicated  if  the  disease  advances  or  if  abscesses 
form  and  rupture,  erasion  in  children,  excision  in  adults. 

Erosion. — A  downward  curved  incision  should  be  made  across 
from  one  condyle  to  the  other  in  front  of  the  joint  below  the  patella. 
The  joint  should  be  freely  opened  and  flexed,  the  diseased  synovial 
membrane  curetted,  any  diseased  areas  in  the  cartilages  and  bone 


798  INJURIES  AND  DISEASES  OF  JOINTS 

thoroughly  scraped  out  by  the  sharp  spoon,  and  the  entire  interior 
of  the  joint  disinfected  with  pure  carbolic  acid  or  a  solution  of  formalin. 
If  there  is  a  mixed  infection  with  marked  sepsis,  the  cavity  should 
be  packed  and  the  leg  held  in  a  flexed  position  (Mayo) ;  in  other  cases 
the  limb  should  be  straightened,  the  wound  united  without  drainage, 
and  the  leg  placed  on  a  posterior  splint.  Recovery  with  bony  ankylosis 
is  the  best  result  to  be  expected. 

Excision  of  the  Knee. — The  joint  is  exposed  in  the  manner  just 
described,  the  leg  acutely  flexed  on  the  thigh,  and  the  patella  and  all 
exposed  portions  of  the  diseased  synovial  membrane  removed.  The 
crucial  ligaments  are  next  divided,  and  the  articular  ends  of  the  femur 
and  tibia  sawn  off  at  such  an  angle  as  to  insure  three  or  four  degrees  of 
flexion  when  the  leg  is  straightened  and  the  cut  surfaces  of  the  bone 
brought  snugly  together.  The  bones  are  held  in  place  by  two  heavy 
catgut  sutures  passed  through  holes  made  with  a  drill.  The  soft  parts 
are  united  and  the  leg  dressed  and  held  in  position  by  a  posterior  splint 
or  plaster  cast.  As  in  other  cases  of  progressive  tuberculous  joint 
disease,  amputation  may  be  necessary  as  a  life-saving  measure. 

The  prognosis  in  tumor  albus  of  the  knee  is  less  serious  than  in 
tuberculous  disease  of  the  spine  or  hip.  Excellent  functional  results 
are  often  obtained  by  early  painstaking  conservative  treatment. 
The  result  of  excision  in  adult  cases'  is  generally  satisfactory.  The 
death  rate  is  low. 

Tuberculous  Arthritis  of  the  Ankle. — Tuberculous  arthritis  of  the 
ankle  is  a  comparatively  rare  affection.  Two-thirds  of  the  cases  occur 
in  individuals  under  twenty  years  of  age.  The  disease  attacks  the 
astragalus  primarily  in  the  majority  of  instances,  but  it  may  occur 
in  either  malleolus. 

Symptoms. — The  disease  not  infrequently  follows  a  sprain,  which 
injur}'  may  act  as  an  exciting  cause,  either  by  lowering  the  resistance 
of  the  joint  tissues,  or  by  awakening  a  latent  bone  focus.  There  are 
stiffness  and  pain  about  the  joint,  with  limitation  of  motion  and  the 
formation  of  boggy  swellings  in  front  of  and  behind  the  malleoli.  The 
patient  limps,  and  in  walking  the  foot  may  be  rotated  outward.  There 
are  well-marked  muscular  rigidity  and  some  atrophy  of  the  muscles 
of  the  calf. 

If  the  disease  is  limited  to  the  subastragaloid  joint,  there  is  pain  on 
lateral  movement  of  the  os  calcis;  plantar  and  dorsal  flexion  may  be 
perfect  (Whitman). 

Treatment. — The  foot  should  be  encased  in  a  plaster  cast,  which 
prevents  all  motion  in  the  joint  and  keeps  it  at  a  right  angle  with  the 
axis  of  the  leg,  and  protected  from  all  use  by  crutches. 

Operative  treatment  should  be  delayed  as  long  as  there  is  any  hope 
of  recovery  by  conservative  measures,  as  the  results  of  excision  or 
arthrectomy  are,  as  a  rule,  unsatisfactory.  Whitman  strongly  advises 
removal  of  the  astragalus  when  this  is  found  to  be  the  seat  of  the 
primary  focus.     To  accomplish  this,  the  joint  should  be  freely  opened 


TUBERCULOUS  DISEASE  OF  SPECIAL  JOINTS  799 

from  the  outside  by  a  curved  incision  beneath  the  external  malleolus, 
and  extending  well  forward  over  the  joint.  The  peronei  tendons  are 
divided,  the  external  lateral,  and  if  necessary  part  of  the  anterior 
and  posterior  ligaments  are  incised,  the  foot  sharply  inverted  until 
the  sole  is  directed  upward,  sacrificing  the  internal  malleolus  if  neces- 
sary. The  astragalus  is  separated  from  its  connections  with  the  other 
bones  of  the  tarsus;  the  os  calcis  is  shaped  to  fit  the  tibiofibular 
mortice,  the  foot  replaced,  the  ligaments  and  tendons  united  and  the 
cutaneous  wound  sutured  with  superficial  drainage. 

Tuberculous  Disease  of  the  Other  Tarsal  Bones. — Tuberculous 
disease  of  the  other  tarsal  bones  is  occasionally  encountered.  Of 
these,  the  calcaneum  and  cuboid  are  the  ones  most  frequently  affected. 
The  treatment  differs  in  no  respect  from  thatof  other  tuberculous  joints. 

Tuberculous  Arthritis  of  the  Shoulder. — Tuberculous  arthritis  of 
the  shoulder  is  a  rare  affection.  The  disease  may  begin  in  the  head 
of  the  humerus  or  in  the  glenoid  cavity. 

Symptoms. — The  earliest  symptoms  are  pain,  stiffness,  muscular 
spasm,  and  swelling.  The  pain  may  be  referred  to  a  point  near  the 
insertion  of  the  deltoid  muscle.  A  tender  point  is  generally  found  just 
below  the  tip  of  the  acromion.  Fever  and  general  failure  of  health 
occur  late.  Muscular  atrophy  may  be  well  marked,  especially  of  the 
deltoid.  The  bone  is  generally  enlarged,  and  the  entire  region  of  the 
joint  appears  broadened.  Abscesses  may  occur  and  point  near  the 
anterior  or  posterior  border  of  the  deltoid  muscle. 

Treatment. — The  treatment  should  be  the  same  as  in  other  tubercu- 
lous joint  affections:  rest,  fixation,  and  the  avoidance  of  jars  and 
other  traumata.  The  use  of  the  sling  and  chest-binder  will  often  give 
relief,  or  the  plaster  spica  of  the  shoulder  and  arm  may  be  employed. 

Excision  of  the  shoulder  may  be  required  if  the  disease  is  progressive. 

The  Anterior  Method. — A  longitudinal  anterior  incision  should  be 
made  either  through  the  deltoid  muscle  or  between  it  and  the  pectoralis 
major.  The  joint  should  be  opened  and  the  head  of  the  bone  resected 
by  the  subperiosteal  method,  if  that  is  possible.  This  saves  the 
attachment  of  the  muscles  and  renders  more  probable  future  use  of 
the  arm.  After  the  diseased  tissues  are  thoroughly  removed  the  wound 
should  be  closed  without  drainage. 

Kocher's  Posterior  Method. — The  incision  runs  from  the  tip  of  the 
acromion  backward  along  the  posterior  border  to  the  spine  of  the 
scapula,  turns  sharply  downward  to  the  posterior  fold  of  the  axilla. 
The  supraspinatus  and  infraspinatus  attachments  are  cut.  The 
posterior  margin  of  deltoid  is  cut  and  with  a  chisel  the  root  of  the 
acromion  is  severed.  This  with  the  deltoid  is  carried  outward,  the 
fibres  of  the  external  rotators  are  cut  exposing  the  capsule  which  is 
opened,  and  the  diseased  matter  removed.  This  completed,  the 
acromion  is  sutured  in  place  and  muscles  and  skin  resutured.  In  the 
majority  of  instances  in  which  recovery  follows,  a  fairly  useful  limb 
results. 


800  INJURIES  AND  DISEASES  OF  JOINTS 

Tuberculous  Arthritis  of  the  Elbow. — -Tuberculous  arthritis  of  the 
elbow  is  more  frequent  than  disease  of  the  shoulder  or  wrist.  It  is 
common  in  early  adult  life.  The  primary  infection  may  be  in  the 
olecranon  or  the  external  condyle  of  the  humerus. 

Symptoms. — The  symptoms  are  pain,  stiffness,  and  limitation  of 
motion  in  the  joint.  Inability  to  extend  the  forearm  completely  is 
often  the  earliest  sign  of  the  disease.  The  joint  later  becomes  enlarged, 
the  swelling  at  first  appearing  on  either  side  of  the  olecranon  and  tendon 
of  the  triceps  and  obliterating  the  normal  depressions  in  these  localities. 
As  the  disease  advances  the  joint  becomes  fixed,  usually  in  a  position 
midway  between  flexion  at  a  right  angle  and  full  extension.  The 
swelling  increases  and  produces  a  fusiform  boggy  tumor.  Suppuration 
may  occur,  sinuses  form,  and  the  entire  articulation  becomes  a  pulpy 
granulating  mass. 

Treatment. — The  conservative  treatment  of  this  joint  should  not  be 
too  long  attempted,  as  the  results  are  not  satisfactory.  If  fixation 
and  general  hygienic  measures  do  not  promptly  arrest  the  progress 
of  the  disease,  excision  is  indicated. 

Excision  of  the  elbow  may  be  accomplished  in  the  following  manner: 
Under  general  anesthesia  a  longitudinal  incision  is  made  over  the  back 
of  the  joint,  the  centre  of  which  will  lie  over  the  olecranon.  When  all 
the  tissues  are  divided  down  to  the  bone  and  well  retracted,  the  perios- 
teum of  the  olecranon  and  upper  part  of  the  ulna  should  be  incised 
together  with  those  of  the  humerus,  and  the  soft  parts  separated  from 
the  bones  on  either  side  until  the  condyles  are  freely  exposed,  care 
being  taken  to  avoid  injury  to  the  ulnar  nerve.  The  arm  is  then 
acutely  flexed  and  the  articular  surfaces  of  both  bones  made  to  protrude 
from  the  wound.  In  erasion  of  the  joint  only  the  diseased  portion  is 
curetted  away  while  in  excision  the  ends  are  totally  removed.  Care 
is  taken  in  exposing  the  joint  to  preserve  the  anconeus  fascial  expan- 
sion of  the  triceps  so  that  subsequent  motion  may  be  secured.  If 
primary  union  occurs  an  attempt  may  be  made,  two  or  three  weeks 
after  operation,  to  change  the  position  of  the  arm — increasing  or 
diminishing  the  degree  of  flexion  every  forty-eight  hours.  In  this 
way  anchylosis  occasionally  may  be  avoided. 

Tuberculous  Arthritis  of  the  Wrist. — Tuberculous  arthritis  of  the 
wrist  is  rare  in  childhood,  and  comparatively  infrequent  at  any  age. 
Any  one  or  all  of  the  joints  may  be  affected. 

Symptoms. — The  symptoms  are  pain,  stiffness,  swelling  and  limita- 
tion of  motion,  with  muscular  atrophy  and  general  ill-health.  The 
swelling  is  more  marked  on  the  dorsal  aspect  of  the  wrist,  and  may  be 
fusiform  in  shape.  Fluctuation  may  be  detected  at  any  early  period, 
but  is  soon  replaced  by  a  boggy  induration. 

Treatment. — The  treatment  should  consist  in  rest  on  a  splint  and 
compression,  as  pressure  here  seems  to  give  a  large  measure  of  relief 
(Bradford  and  Lovett).  Excision  of  one  or  more  of  the  bones  of  the 
wrist  is  indicated  in  advanced  disease  but  gives  only  a  fair  prognosis. 

The  best  incision  to  expose  the  lesion  is  a  longitudinal  one  over  the 


TUBERCULOUS  DISEASE  OF  SPECIAL  JOISTS 


801 


back  of  the  wrist,  between  the  extensor  tendons  of  the  thumb  and 
those  of  the  index  finger.  These  tendons  are  separated  with  retractors, 
and  the  long  and  short  extensors  of  the  wrist  brought  into  view  and 
retracted.  The  attachment  of  the  short  extensor  to  the  third  meta- 
carpal bone  is  next  divided,  and  the  carpal  bones  well  exposed  by  wide 
retraction  of  the  tissues.  Only  the  bones  that  are  diseased  should  be 
removed.  The  use  of  the  glutol 
or  formalin  gelatin  powder 
here  and  in  other  tuberculous 
cavities  has  been  found  by 
the  author  to  bring  about 
healthy  granulation  and  often 
complete  healing  in  what 
seemed  to  be  hopeless  cases. 
After  closure  of  the  wound 
with  drainage,  the  arm  should 
be  placed  on  a  palmar  splint 
and  kept  at  rest  until  evidence 
of  tuberculosis  hasdisappeared. 
Amputation  is  often  made 
necessary  because  of  the  un- 
satisfactory result  from  wrist 
resection  and  from  progression 
of  the  disease. 

Sacro-iliac  Disease. — Tuber- 
culosis of  the  sacro-iliac  joint 
is  a  rare  affection.  It  occurs 
chiefly  in  young  adults. 

Symptoms. — The  symptoms 
in  the  beginning  are  obscure, 
and  often  resemble  those  of 
lumbar  Pott's  disease.  There 
is  pain  on  standing  or  walking, 
and  on  pressing  the  iliac  crests 
together;  the  patient  limps,  and 
instinctively  rests  his  weight 
upon  the  healthy  leg.  On 
walking  the  spine  has  a  lateral 

deviation,  and  the  motion  of  the  legs  is  chiefly  below  the  knees.  This 
gives  a  shuffling  characteristic  gait.  A  cold  abscess  may  form  and 
point  in  the  gluteal  region  or  burrow  deep  in  the  pelvis. 

Treatment. — Rest  in  bed,  with  extension  during  the  acute  stage. 
Later,  a  pelvic  binder  and  crutches.  Abscess  in  the  pelvis  may  be 
reached  by  a  posterior  incision  with  resection  of  a  portion  of  the  ileum 
(Van  Hook). 

Neuropathic    Arthropathy. — Neuropathic    arthropathy     (Charcot's 
Joint)  (Fig.  371  j  is  an  example  of  the  reaction  against  normal  irritation 
51 


Fig.  371. — Tabetic  arthropathy  (Charcot's 
disease)  of  the  knee-joint.  Insane  patient 
with  locomotor  ataxia.  Relaxation  of  liga- 
ments. Effusion  and  numerous  loose  bodies 
in  joint.  Absorption  of  articular  surfaces. 
Functionally  useless,  painless  joint.  (Carnett). 


802  IX JURIES  AND  DISEASES  OF  JOINTS 

of  the  perverted  adaptive  power  of  a  joint  due  to  disturbance  of  nerve 
supply.  From  pathological  study  it  has  been  inferred  that  the  process 
is  the  direct  result  of  the  Spirocheta  pallida,  but  this  is  yet  to  be 
established.  It  most  frequently  follows  tabes;  more  rarely  syringo- 
myelia and  anterior  poliomyelitis.  The  pathology  is  the  same  as  the 
fungous  type  of  chronic  arthritis  with  effusion,  degenerative  changes 
and  bony  outgrowths  predominating. 

Symptoms. — The  symptoms  have  an  acute  onset  reaching  a  maximum 
in  a  few  days  and  often  going  on  to  complete  joint  destruction  in  a 
few  weeks.  The  joints  involved  correspond  to  the  section  of  the  cord 
affected,  usually  the  knee,  less  often  the  shoulder,  hip,  and  elbow. 
It  is  usually  monarticular  but  may  be  bilateral.  The  joint  is  greatly 
distended.  There  is  great  abnormal  mobility  with  subluxation.  The 
skin  is  normal  with  dilated  veins.  There  may  be  subcutaneous  edema. 
Pain  is  absent  and  the  x-rays  present  a  picture  of  bony  overgrowth 
and  degeneration  of  the  bone  end  with  osteoporosis. 

Treatment. — Treatment  is  by  mechanical  support,  rest,  and  meas- 
ures directed  against  the  original  infection. 

Pulmonary  Osteoarthropathy. — Pulmonary  osteoarthropathy  is  a 
condition  occurring  in  chronic  inflammation  of  the  intrathoracic  struc- 
tures and  characterized  by  the  thickening  of  periosteum  of  the  long 
bones  and  chronic  hyperplastic  inflammatory  processes  in  the  joints 
similar  to  chronic  progressive  polyarthritis.  Its  exact  nature  is  un- 
known but  from  the  pathology  and'  clinical  course  it  has  been  assumed 
to  be  infectious. 

Chronic  Synovitis. — Chronic  synovitis  is  the  result  of  continued 
mechanical  irritation  by  a  foreign  body,  loose  meniscus,  thickened 
synovial  fringe,  badly  approximated  joint  surfaces,  as  in  static  changes 
due  to  flat  foot  or  knock-knee,  and  possibly  by  a  bloody  effusion  into 
the  joint.     It  is  also  caused  by  mild  gout  and  by  avirulent  infection. 

Symptoms. — Symptoms  are  those  of  a  distended  joint  with  fluctua- 
tion, slight  discomfort  and  limp.  The  course  is  chronic  dependent  on 
the  cause. 

Treatment  of  chronic  serous  synovitis  consists  in  rest,  counter- 
irritation,  massage,  hydrotherapy,  compression,  and  the  use  of  hot- 
air  baths.  Counter-irritation  is  produced  best  by  the  application  of 
the  actual  cautery,  fly  blisters,  or  painting  with  iodine;  compression 
by  the  use  of  the  rubber  bandage  or  an  elastic  stocking  or  cap;  the 
hot-air  bath  requires  a  special  apparatus,  which  is  pictured  in  Fig. 
372  . 

If  these  means  fail,  the  joint  may  be  emptied  by  aseptic  aspira- 
tion and  immediate  compression  applied  by  a  rubber  bandage;  or 
open  arthrotomy  may  be  performed  for  purposes  of  exploration.  This 
treatment  should  be  followed  by  a  period  of  rest  of  from  two  to  three 
weeks. 

A  form  of  intermittent  swelling  of  the  joint  (  Hydrops  artiddorum 
intermittens)  occurs  with  marked  regularity,  is  bilateral,  of  sudden 


NEW  GROWTHS  OF  JOINTS 


so:; 


onset  and  subsidence,  but  chronic  course  and  has  been  thought  to 
belong  to  the  same  class  as  angeioneurotic  edema. 

Hemarthrosis. — Hemarthrosis  is  a  rare  condition  occurring  in 
bleeders  usually  in  the  young.  It  occurs  spontaneously  or  after 
insignificant  trauma.  There  are  in  the  early  attacks  signs  of  clotted 
blood  in  the  joint  with  effusion  which  may  subside  with  no  sequela3. 
With  more  frequent  attacks  there  are  irritation  and  the  production 
of  a  pathological  and  clinical  picture  diagnosed  with  difficulty  from 
tuberculosis  and  chronic  progressive  arthritis,  with  fungous  and  bony 
growth  and  erosion  of  the  cartilages,  producing  joint  deformity  and 
contractures. 

Treatment. — The  treatment  is  by  absolute  rest  and  mild  pressure, 
together  with  the  treatment  of  the  hemophilia. 


Fig.  372. — The  Frazier-Lentz  hot-air  apparatus. 


NEW  GROWTHS  OF  JOINTS. 


New  growths  of  the  joints  may  be  osteoma,  chondroma,  and  lipoma. 
Whether  these  are  inflammatory  products  or  true  neoplasms  is  difficult 
to  decide. 

Osteoma,  composed  of  cancellous  bone,  occurs  at  the  bone  end,  grows 
at  the  edge  of  the  cartilage,  often  becomes  pedunculated  or  broken  off 
from  the  bone,  when  it  acts  as  a  foreign  body. 

Chondroma  of  the  articular  cartilage  is  rare.  In  hypertrophied 
joint  fringes  especially  in  villous  arthritis  there  may  be  the  forma- 


804  INJURIES  AND  DISEASES  OF  JOINTS 

tion  of  cartilaginous  centres  through  metaplasia.  In  structure  they 
do  not  differ  from  chondromata.  They  are  the  most  frequent  source 
of  joint  mice. 

Lipoma  of  the  joint  occurs  as  a  shaggy  growth  of  the  synovial 
membrane  (lipoma  arborescens)  in  gross  appearance  like  villous  ar- 
thritis but  on  microscopical  section  showing  adult  and  embryonal 
fat  cells. 

Malignant  tumors  are  extremely  rare. 

The  treatment  of  all  new  growths  is  excision. 


ANKYLOSIS. 

The  loss  of  motion  in  a  joint  is  spoken  of  as  ankylosis.  This  may  be 
due  to  trauma  resulting  in  fracture  and  bony  deformity;  to  inflam- 
mation, giving  rise  to  fibrous  adhesions,  loss  of  cartilage,  and  bony 
union  of  the  joint  surfaces  (synostosis);  to  exostoses;  to  muscular 
contractures;  or  to  the  formation  of  periarticular  adhesion  or  cica- 
trices. 

Treatment. — The  prophylactic  treatment  by  massage,  passive 
motion,  hydrotherapy,  electricity,  etc.,  has  already  been  mentioned 
in  the  sections  devoted  to  the  various  injuries  and  joint  lesions  giving 
rise  to  ankylosis.  After  ankylosis  has  once  occurred,  however,  the 
problem  is  a  far  more  difficult  one. 

When  the  ankylosis  is  due  to  muscular  contractures  or  scar  tissue, 
much  can  be  accomplished  by  tenotomy  and  plastic  operations;  when 
due  to  vicious  union  of  fractures  involving  the  joint  surfaces,  open 
operation  and  readjustment  of  the  fragments  will  sometimes  bring 
about  a  restoration  of  function.  In  the  early  stage  of  fibrous  ankylosis, 
forcible  rupture  of  the  adhesions  under  general  anesthesia,  followed 
by  persistent  passive  motion  will  occasionally  be  successful,  but  the 
pain  is  often  severe,  and  a  gradual  return  to  the  former  condition 
almost  inevitable.  In  chronic  non-tuberculous  arthritis  where  there 
is  a  marked  tendency  to  bone  formation,  forced  movements  not 
infrecpiently  accentuate  the  pathologic  progress  and  do  positive  harm. 

A  large  number  of  experiments  have  been  made  with  a  view  to 
restoring  motion  in  these  hopelessly  ankylosed  joints  by  means  of 
open  operation,  separation  of  the  joint  surfaces,  removal  of  the  syno- 
vial membrane  and  implanting  various  substances,  as  ivory,  celluloid 
or  silver  plates,  rubber  tissue,  or  animal  membrane  between  the 
articulating  bones.  Some  brilliant  successes  have  been  obtained  by 
Murphy  and  others  in  the  use  of  layers  of  aponeurosis,  fatty  tissue 
and  muscle  for  transplantation,  either  attached  by  pedicles  or  freely 
transplanted  from  one  part  of  the  body  to  another.1  Buchmann2  has 
recently  reported  2  cases  where  he  successfully  transplanted  an  un- 

1  Jour,  of  Amer.  Med.  Assoc,  May  20,  1905. 

2  Zentralblatt  fur  Chirurgie,  1908,  No.  19. 


ARTHRODESIS  si  >."> 

opened  first  metatarsophalangeal  joint  to  the  elbow  region  after 
excision  of  the  ankylosed  elbow-joint.  In  both  instances  the  wounds 
healed  and  painless  voluntary  motion  was  obtained,  in  one  ease  through 
an  arc  of  30  and  in  the  other  through  an  arc  of  70  degrees.  Lexer1 
has  successfully  transplanted  the  articular  surfaces  of  the  knee-joint 
with  crucial  ligaments,  from  a  freshly  amputated  extremity. 

Further  experiments  along  these  lines,  it  is  hoped,  will  furnish  data 
upon  which  to  base  final  conclusions. 

ARTHRODESIS. 

In  certain  cases  of  paralysis,  or  in  other  instances  where  an  exces- 
sive and  uncontrolled  mobility  of  a  joint  is  present,  the  usefulness 
of  the  limb  may  be  increased  by  obtaining  firm  bony  ankylosis. 
To  the  procedure  which  produces  such  ankylosis,  the  term  arthrodesis 
is  applied. 

The  method  usually  adopted  is  to  expose  the  articular  surfaces  by 
a  suitable  incision,  and  then  to  remove  by  knife,  curet,  or  saw  the 
greater  part  of  the  articular  cartilages  after  which  the  wound  is  closed 
and  the  limb  retained  in  the  most  favorable  position  by  a  plaster  cast. 
Where  numerous  small  bones  are  to  be  fixed  and  where  the  complexity 
of  the  joint  structure  would  make  such  a  procedure  tedious  or  danger- 
ous good  results  have  been  obtained  by  the  use  of  metal  spikes  fasten- 
ing the  bones  together,  or  even  the  implantation  of  bony  splints,  by 
free  transplantation,  in  such  a  way  as  to  secure  immobility  of  the 
joint.  The  operation  is  most  frequently  indicated  in  cases  of  infantile 
paralysis  of  the  lower  extremity,  where  nerve  or  tendon  grafting  is  for 
any  reason  impracticable. 

The  cut  surfaces  are  held  by  phosphor-bronze  wire,  chromic  catgut 
sutures,  metal  plates,  or  bony  splints. 

1  Arch.  f.  klin.  Chir.,  vol.  xc,  No.  2. 


CHAPTER  XXIX. 
FRACTURES. 

The  term  fracture,  in  its  surgical  sense,  signifies  a  break  or  violent 
separation  into  two  or  more  fragments  of  a  bone  or  cartilage. 

A  simple  fracture  is  one  which  is  covered  by  unbroken  soft  tissues. 
A  compound  fracture  is  one  in  which  the  bone  lesion  is  exposed  by  a 
wound  of  the  overlying  parts.  A  comminuted  fracture  is  one  in  which 
the  bone  or  cartilage  is  broken  into  a  number  of  small  fragments. 
The  terms  transverse,  oblique,  longitudinal,  spiral,  T-  or  Y-shaped,  are 
commonly  used  to  indicate  the  general  direction  of  the  line  or  lines  of 
separation. 

A  fracture  is  said  to  be  impacted,  when  one  fragment  is  forcibly 
driven  into  another  and  remains  more  or  less  fixed  in  that  position. 
The  terms  single,  double,  multiple,  recent,  old,  united,  and  ununited, 
are  frequently  used  in  describing  fractures,  the  significance  of  which 
will   be   readily   understood. 

Injuries  of  bene  or  cartilage  which  do  not  result  in  complete  separa- 
tion are  sometimes  spoken  of  as  incomplete  fractures.  These  are  sub- 
divided into  fissures  or  cracks  without  displacement  of  fragments; 
green-stick  fractures,  where  a  portion  of  the  shaft  of  a  long  bone  is 
fissured,  the  remaining  portion  bent — these  conditions  are  not  infre- 
quently encountered  in  children,  and  are  often  difficult  of  recognition; 
depressions,  where  a  portion  of  a  flat  bone  is  driven  inward;  and 
separations  at  the  epiphyseal  line  before  complete  union  has  been 
effected,  occurring  therefore  in  early  life. 

Etiology. — The  predisposing  causes  of  fracture  are,  in  general, 
conditions  which  render  the  bones  more  friable,  such  as  the  physio- 
logic atrophy  of  old  age,  malnutrition  from  any  of  the  wasting 
diseases,  new  growths,  osteomyelitis,  or  the  lesions  of  syphilis  or 
tuberculosis.  The  exciting  causes  of  fracture  are  either  external 
violence,  muscular  action,  or  a  combination  of  both  of  these  agencies. 
External  violence  may  be  direct,  where  the  break  occurs  at  the  point 
of  injury;  or  indirect,  where  it  occurs  at  a  distance  from  the  point  of 
application  of  the  injuring  force.  A  depressed  fracture  of  the  skull 
from  the  blow  of  a  hammer  would  be  an  example  of  a  fracture  by  direct 
violence;  a  fracture  of  the  clavicle  from  a  fall  on  the  hand  would  be 
an  example  of  one  by  indirect  violence;  a  fracture  of  the  patella 
occurring  during  an  attempt  to  jump  would  be  an  example  of  one  by 
muscular  action;  a  blow  on  the  point  of  a  rigidly  flexed  elbow,  fractur- 
ing the  olecranon,  would  furnish  an  example  of  a  fracture  by  both 
direct  violence  and  muscular  action. 


PLATE    XXIII 


After/4i"ear 


Time  of  Bony  Union  of  the  Various  Epiphyseal  Junctions. 


1!  UP  AIR  OF  FRACTURES 


807 


Repair  of  Fractures. — The  processes  of  repair  in  fractured  bones  arc 
practically  the  same  as  in  wounds  of  the  soft  parts.  As  the  bone  breaks 
there  is  a  considerable  laceration  of  the  surrounding  muscles  and 
fasciae,  blood  is  effused,  and  the  periosteum  may  be  stripped  from  the 
ends  of  the  bone.  If  the  fracture  is  quickly  reduced  and  the  bony 
fragments  are  accurately  replaced  and  securely  held  in  their  normal 
position,  the  process  is  very  simple.  There  is,  at  first,  a  reactionary 
hyperemia  followed  by  an  exudation  of  lymph  which  solidifies  around 
the  broken  fragments,  and  encloses  the  blood  clot,  torn  muscle,  fascia, 
and  periosteum.     This  soon  becomes  vascularized,  and  is  gradual 


Fig.  373. — Fracture  three  weeks  old;  perios- 
teal and  medullary  callus  partly  ossified,  partly 
cartilaginous:  P,  periosteum;  K,  bone;  M,  med- 
ulla.    (Tillmanns.) 


Fig.  374. — Fracture  healed 
with  deformity  (callus  luxur- 
ians).     (Tillmanns.) 


converted  into  fibrous  tissue:  it  constitutes  the  provisional  callus,  and 
is  the  hard  fusiform  mass  felt  around  the  broken  fragments  after  the 
first  week.  At  a  later  period  this  mass  becomes  calcified;  the  part 
between  the  broken  fragments  remains  as  the  permanent  callus;  the 
external  or  ensheathing  callus,  as  well  as  the  internal,  central  or 
medullary  callus,  is  gradually  absorbed  (Fig.  373). 

If  the  broken  fragments  are  not  accurately  replaced,  if  there  is 
overriding,  or  if  there  is  constantly  more  or  less  motion  between  the 
fragments,  the  process  is  slower,  the  primary  exudate  greater,  and  more 
or  less  of  the  ensheathing  callus  may  remain  as  a  permanent  bridge 
between  the  fragments  (Fig.  374). 


80S  FRACTURES 

In  compound  fractures,  if  the  wound  can  be  thoroughly  cleansed 
and  united,  primary  union  may  take  place  and  the  process  may  be 
the  same  as  in  a  simple  fracture.  If,  however,  the  wound  is  infected 
or  for  any  other  reason  cannot  be  closed,  healing  takes  place  by  gran- 
ulation. Necrosis  of  the  denuded  ends  of  the  bone  is  very  likely  to 
occur  under  these  conditions,  small  fragments  from  time  to  time 
becoming  detached  and  appearing  among  the  granulations,  indefinitely 
delaying  permanent  closure  of  the  wound  and  repair  of  the  fracture. 
If  the  soft  parts  heal  rapidly,  the  necrosed  fragments  of  bone  may 
become  surrounded  by  the  ensheathing  callus  and  absorbed,  or  later 
removed  by  operation. 

Diagnosis. — Distinction  must  be  made  between  the  symptoms  of 
the  fracture  itself,  those  due  to  any  displacement  of  fragments,  and 
those  due  to  associated  lesions.  The  subjective  symptoms  of  the  frac- 
ture are  pain  and  impairment  of  function.  The  objective  symptoms 
are  localized  tenderness  and  abnormal  mobility.  Deformity  and 
crepitus  are  associated  with  displacement  of  the  fragments.  The 
swelling,  ecchymosis  and  abrasions  of  the  outlying  parts  belong  to  the 
associated  injuries. 

Deformity  often  may  be  appreciated  by  inspection  alone,  by 
palpation,  or  by  comparative  measurements.  Not  infrequently  the 
deformity  is  produced  only  by  manipulation. 

Abnormal  mobility  may  be  made  evident  by  the  muscular  efforts 
of  the  patient  or  by  the  examination  of  the  surgeon.  Crepitus  is  the 
feeling  imparted  to  the  hand  of  the  examiner  by  the  rubbing  together 
of  two  or  more  fragments  of  bone;  occasionally  it  is  heard  as  well  as 
felt.  An  attempt  to  elicit  this  sign,  however,  should  rarely  be  made  if 
it  involves  additional  trauma. 

In  the  diagnosis  of  fractures  it  is  important  that  a  methodical 
examination  be  made  in  every  suspected  case,  definitely  establishing 
the  presence  or  absence  of  as  many  of  the  above  symptoms  and  signs 
as  can  be  elicited  without  causing  additional  trauma.  The  surgeon 
should  proceed  in  the  following  manner: 

First  obtain  from  the  patient  or  a  witness  an  accurate  account  of 
the  accident;  then  a  statement  of  the  immediately  resulting  impair- 
ment of  function,  as  the  ability  to  walk  after  the  injury  of  a  leg,  use 
of  the  arm  or  hand  after  injury  of  that  member;  the  mental  condition 
after  a  head  trauma;  the  presence  or  absence  of  cough  or  bloody 
expectoration  after  a  crush  of  the  chest;  or  the  passage  of  blood  from 
the  rectum  or  bladder  after  injuries  about  the  pelvis. 

The  part  should  then  be  inspected  after  a  careful  removal  of  the 
clothing.  If  a  wound  of  the  soft  parts  be  found,  suggesting  the  pos- 
sibility of  the  fracture  being  compound,  this  at  once  should  be  swabbed 
with  tincture  of  iodine  and  protected  by  a  clean  dressing  to  avoid 
further  contamination  during  the  subsequent  examination.  In  injur- 
ies accompanied  by  marked  and  characteristic  deformity  it  is  often 
possible  to  arrive  at  a  positive  diagnosis  of  fracture  at  once  by  inspec- 


DIAGNOSIS  K09 

tion  of  the  part,  and  in  such  case  it  is  preferable  not  to  proceed  further 
with  the  examination  until  ready  to  reduce  the  fracture  and  apply  the 
first  dressing,  as  repeated  moving  and  manipulation  of  fractured  limbs, 
especially  if  accompanied  by  severe  injury  of  the  soft  parts,  is  unneces- 
sary, extremely  painful,  and  dangerous. 

If  the  diagnosis  is  not  established  by  inspection,  the  limb  should 
than  be  gently  palpated  and  the  area  of  greatest  tenderness  ascer- 
tained. The  outline  of  each  bone  should  next  be  felt  from  its  upper 
to  its  lower  extremity,  and  any  deformity  or  point  of  special  tender- 
ness noted.  Abnormal  mobility  should  be  gently  sought  for  and  the 
exact  point  noted;  crepitus  if  obtained  is  a  very  valuable  symptom  but 
search  for  it  adds  further  unnecessary  trauma.  In  fractures  of  the 
shaft  of  the  femur,  by  simply  placing  a  hand  under  the  seat  of  injury 
and  raising  the  limb-,  angular  deformity,  mobility,  and  crepitus  may 
often  be  demonstrated.  In  other  instances,  especially  in  fractures 
near  the  joints,  gentle  traction  and  rotation  will  often  elicit  these 
signs.  In  fractures  of  both  bones  of  the  leg  .these  signs  are  easily 
made  evident  by  the  gentlest  manipulation.  Fractures  about  the 
wrist,  elbow,  or  shoulder  are  generally  made  out  by  their  character- 
istic deformity  or  by  careful  palpation  during  flexion,  extension,  and 
rotation  of  the  joint  with  traction  on  the  limb.  Deformity  and  abnor- 
mal mobility  are  generally  absent  in  fractures  of  the  ribs.  Crepitus 
is  obtained  best  by  pressure  over  the  ribs  during  deep  inspiration  and 
expiration.  It  often  may  be  elicited  by  the  use  of  the  stethoscope 
placed  over  the  point  of  greatest  tenderness,  the  grating  sound  being 
heard  during  the  movements  of  respiration.  Mobility  and  crepitus 
in  fractures  of  the  pelvis  are  obtained  best  by  pressing  together  the 
crests  of  the  ilia  or  by  direct  palpation  of  the  pubic  arch,  rami,  or 
sacrum  by  rectal  or  vaginal  examination.  In  fractures  of  the  skull 
or  spine  the  above-mentioned  positive  signs  are  often  wanting;  the 
diagnosis  must  be  made  by  the  z-rays,  exploratory  operation  or  the 
evidences  of  visceral  injury. 

The  use  of  the  a-rays  in  the  diagnosis  of  fractured  bones  has  been 
found  of  the  greatest  service,  and  their  employment  should  be  a  matter 
of  routine  wherever  fractures  are  treated.  While  it  may  give  an  exag- 
gerated picture  of  deformity  in  comparatively  unimportant  variations 
from  the  normal,  and  its  constant  use  may  in  a  measure  lead  us  to 
ignore  and  discard  other  methods,  yet  the  fact  must  be  admitted  that 
by  its  employment  a  far  more  accurate  idea  of  a  given  injury  can  be 
obtained  than  by  any  other  method,  and  its  use  should  be  strongly 
recommended  wherever  it  is  possible.  Plates  should  always  be  taken 
in  two  different  planes:  before  reduction  if  possible,  so  that  the  at- 
tempt at  reduction  shall  be  as  simple  and  purposeful  as  possible; 
and  always  after  reduction  to  ensure  the  best  possible  adjustment.  It 
is  safer  to  again  examine  the  fracture  in  this  way  at  later  intervals 
to  be  sure  the  reduction  has  been  maintained. 


810  FRACTURES 

Complications. — In  nearly  all  fractures  there  is  more  or  less  bruising 
or  injury  of  the  soft  parts,  due  to  the  trauma  which  produced  the 
bone  lesion.  When  this  is  not  accompanied  by  extensive  laceration 
of  the  skin  or  muscles,  nor  by  injury  to  the  nerve  trunks  or  vessels,  it 
is  unimportant. 

Compound  Fractures. — If  a  wound  in  the  soft  parts  leads  to  the  seat 
of  fracture,  constituting  a  compound  fracture,  the  condition  is  serious, 
and  should  receive  the  most  thorough  and  prompt  attention,  for  infec- 
tion in  a  case  of  compound  fracture  gives  rise  frequently  to  the  most 
virulent  forms  of  septicemia.  Previous  to  the  introduction  of  the 
modern  aseptic  and  antiseptic  methods  of  wound  treatment,  in  the 
great  majority  of  instances  compound  fractures  of  the  extremities 
were  rapidly  fatal  or  the  patient  recovered  only  after  either  amputa- 
tion or  a  prolonged  osteomyelitis,  and  while  the  modern  methods  of 
dealing  with  such  conditions  have,  to  a  great  extent,  removed  these 
dangers,  and  by  appropriate  treatment  the  majority  of  such  cases  may 
be  saved,  it  should  not  be  forgotten  that  in  compound  fracture  of  any 


Fig.  375. — Volkmanu's  contracture. 

of  the  larger  bones  we  have  a  condition  which  may  result  fatally,  and 
one  in  which  this  result  can  be  avoided  only  by  the  most  thorough 
antiseptic  treatment. 

Ischemic  Paralysis. — This  rare  but  important  complication  of 
fracture  is  a  pressure  paralysis,  caused  by  the  temporary  absence  from 
the  tissues  of  oxygenated  blood,  and  often  results  in  complete  and 
permanent  loss  of  function  of  an  extremity.  The  lesion  was  first 
described  by  Volkmann  in  1880.  Since  that  time  many  cases  have 
been  reported  in  the  literature.  It  is  probable  that  the  lesion  is  far 
more  common  than  is  generally  supposed,  but  that  it  is  not  generally 
recognized,  or  the  symptoms  attributed  to  other  causative  factors. 
In  the  great  majority  of  cases  the  lesion  occurs  in  children  and  in  the 
upper  extremity  (Fig.  375). 

Tight  bandaging,  the  application  of  a  plaster-of- Paris  circular  cast 
or  of  snugly  applied  wooden  splints  immediately  after  an  injury  may 
cause  progressively  increasing  pressure  on  the  soft  tissues  as  the  reac- 
tionary swelling  occurs.  This  gives  rise  to  an  acute  ischemia  of  the 
parts,  which,  if  unrelieved  for  six  or  more  hours,  produces  marked 


COMPLICATIONS  811 

degenerative  changes  in  the  muscles  and  nerves,  resulting  in  paralysis, 
contractures,  sensory,  and  trophic  disturbances.  Other  factors  are 
sometimes  present,  as  large  hematomata,  thrombosis  of  the  vessels, 
and  direct  nerve  injury,  but  the  essential  feature  is  an  absence  of 
blood  supply  to  the  muscles. 

The  symptoms  of  this  condition  are  pain,  coldness,  edema,  and 
cyanosis  of  the  distal  portion  of  the  extremity,  with  the  possible 
formation  of  blebs.  If  unrelieved,  paralysis  quickly  follows,  asso- 
ciated with  a  marked  shortening  of  the  flexor  muscles,  resulting  in 
acute  flexion  of  the  fingers  which  cannot  be  overcome  by  the  appli- 
cation of  any  reasonable  amount  of  force.  Numbness  and  some- 
times complete  sensory  anesthesia  are  present,  with  thin  glossy  skin 
and  atrophic  nails.  In  the  severest  cases  gangrene  of  the  extremity 
may  occur.  At  a  later  period  the  anesthesia  and  trophic  disturbances 
may  disappear,  but  the  contraction  of  the  muscles,  which  is  due  to 
connective-tissue  change,  is  permanent.  The  features  which  serve  to 
distinguish  this  condition  from  other  forms  of  paralysis  are  the  simul- 
taneous occurrence  of  the  paralysis  and  contractions,  and  the  inability 
to  extend  the  fingers  without  flexion  of  the  wrist. 

The  prognosis  in  ischemic  paralysis  is  generally  unfavorable.  Unless 
the  condition  can  be  relieved  before  six  hours  have  elapsed,  permanent 
damage  results  to  the  muscles. 

The  treatment  should  consist  in  prompt  removal  of  splints  and 
tight  bandages  as  soon  as  the  condition  is  recognized.  Fixation  of  the 
fractured  bones  should  be  disregarded  for  a  time,  and  massage,  pas- 
sive motion,  hot  and  cold  baths,  electricity,  and  Bier's  hyperemic 
treatment  applied  to  restore  the  circulation  and  improve  the  nutrition 
of  the  muscles.  At  a  later  period  if  the  anesthesia  and  trophic  disturb- 
ances persist,  the  nerves  should  be  exposed,  freed  from  their  fibrous 
beds,  and  transplanted  to  the  subcutaneous  tissue  or  surrounded  by  fat 
or  Cargile  membrane.  Lengthening  the  flexor  tendons  or,  better  still, 
shortening  the  arm  by  a  resection  of  from  2  to  4  cm.  of  the  radius  and 
ulna,  occasionally  has  overcome  deformity  and  enabled  the  shortened 
but  not  wholly  degenerated  flexor  muscles  to  functionate. 

Fat-embolism  is  a  plugging  of  the  pulmonary  capillaries  with  free 
fat-globules.  The  fat-globules  are  derived  from  the  marrow,  and  are 
supposed  to  gain  entrance  to  the  blood  current  through  the  venous 
sinuses  in  the  broken  bone.  They  are  first  arrested  in  the  capillaries 
and  smallest  arterioles  of  the  lungs,  but  are  occasionally  found  in  the 
brain,  kidneys,  and  other  viscera.  The  symptoms  are  those  of  an  exag- 
gerated shock,  with  rapid,  labored  respiration,  and  cyanosis.  There 
also  may  be  restlessness,  delirium,  and  coma.  The  condition  often 
is  rapidly  fatal,  and  is  occasionally  mistaken  for  pneumonia  or  delirium 
tremens. 

Delirium  Tremens  seems  to  follow  fractures  more  frequently  than 
other  injuries  of  the  same  character,  due  possibly  to  the  fact  that  the 
fracture  frequently  follows  a  state  of  intoxication,  and  the  sudden 


812  FRACTURES 

withdrawal  of  the  alcohol  after  the  injury  gives  rise  to  the  symptoms. 
It  is  advisable  under  such  circumstances  to  give  a  certain  amount  of 
alcohol,  preferably  ale,  during  the  first  few  days  after  such  an  injury, 
and  to  combat  the  early  restlessness  and  insomnia  by  generous  doses 
of  sodium  bromide,  digitalis,  and  chloral. 

Injuries  of  the  veins  may  result  in  extensive  extravasation  of  blood, 
forming  hematomata,  and  these  by  pressure  may  cause  edema  or  even 
gangrene. 

Occasionally  arterial  wounds  give  rise  to  traumatic  aneurisms. 

Injury  to  the  main  arterial  trunk  of  a  limb  may  cause  a  rapidly 
advancing  gangrene  requiring  amputation. 

The  late  complications  of  fracture  are  limitation  of  joint  motion 
from  intra-articular  adhesions,  misplaced  bony  fragments,  connective- 
tissue  changes  in  adjacent  soft  tissues,  or  exuberant  callus;  paralysis 
from  laceration  of  a  nerve  trunk  or  from  pressure  of  callus;  muscular 
weakness  from  atrophy  or  adhesions  between  tendons  and  their  sheaths; 
delayed  union  or  non-union,  which  may  be  due  simply  to  ill  health  or 
deficient  blood  supply,  but  is  generally  caused  by  faulty  position  of 
the  fragments  or  the  interposition  of  a  layer  of  muscle  or  fascia  between 
the  broken  ends  of  the  bone;  pseudarthrosis,  when  after  non-union 
the  ends  of  the  bones  become  rounded  and  a  kind  of  joint  cavity  is 
formed  secreting  serous  fluid;  and  vicious  union,  a  union  of  the  frag- 
ments with  deformity,  giving  rise  to  impairment  of  function. 

Treatment  of  Fractures  in  General. — In  the  treatment  of  fractures 
four  principles  should  be  observed:  (1)  To  prevent  further  injury; 
(2)  to  reduce  the  displacement  of  fragments;  (3)  to  maintain  that  re- 
duction; (4)  to  search  for  and  treat  associated  injuries.  In  fractures 
of  the  lower  extremity,  skull,  spine,  or  pelvis,  or  in  the  presence  of 
other  fractures  complicated  by  shock  or  severe  and  painful  contusions, 
the  patient  should  be  transferred  to  his  home  or  a  hospital  on  a 
stretcher.  In  removing  him  to  and  from  the  stretcher,  the  injured 
part  should  be  carefully  guarded  by  the  surgeon  or  protected  by  an 
improvised  splint,  to  prevent  further  injury  of  the  soft  parts.  Fig. 
376  illustrates  an  improvised  pillow  splint  for  fracture  of  the  lower 
leg.  If  there  is  a  wound  of  the  soft  parts  and  a  probability  of  the 
fracture  being  compound,  the  wounded  area  should  be  immediately 
protected  by  an  antiseptic  pad,  and  later  the  entire  limb  shaved, 
scrubbed,  and  otherwise  prepared  as  for  a  surgical  operation. 

In  simple  fractures,  after  the  diagnosis  has  been  established  by 
the  methods  mentioned  above,  in  which  the  greatest  care  and  gentle- 
ness must  be  observed  to  prevent  further  injury;  the  next  step  is 
reduction  of  the  fracture,  or,  as  it  is  usually  spoken  of  by  the  laity, 
"setting  the  bone."  This  may  be  easily  accomplished  in  superficially 
located  bones,  where  there  is  little  or  no  swelling  or  muscular  rigidity 
by  gentle  traction  and  manipulation,  the  reduction  being  evidenced 
by  disappearance  of  the  deformity  and  a  return  to  the  normal  of  the 
outline  of  the  limb.     In  many  instances,  however,  accurate  replace- 


TREATMENT  OF  FRACTURES  IN  GENERAL 


si:; 


ment  is  difficult,  owing  to  swelling,  great  pain,  muscular  rigidity,  and 
the  difficulty  of  determining  with  precision  the  position  of  the  frag- 
ments. In  these  and  in  all  doubtful  fractures,  especially  about  the 
joints,  general  anesthesia  should  be  used  and  the  reduction  accom- 
plished under  the  guidance  of  the  .r-rays. 

The  retention  of  the  fragments  in  their  normal  positions  after  reduc- 
tion, while  often  easy,  will  occasionally  tax  the  ingenuity  of  the  sur- 
geon to  the  utmost.  When  the  fractured  bone  is  held  in  position  by 
strong  layers  of  muscle  and  fascia  passing  from  a  near  and  uninjured 
parallel  bone,  as  in  the  case  of  fracture  of  a  single  rib  or  the  fibula, 
practically  no  retention  apparatus  is  required,  the  treatment  being 
directed  toward  keeping  the  parts  at  rest.  On  the  other  hand,  in 
fractures  of  the  shaft  of  the  femur,  humerus,  clavicle,  or  of  both 
bones  of  the  forearm*,  even  if  once  completely  reduced,  the  bones 
are  not  infrequently  misplaced  by  muscular  action  on  the  broken 
fragments  after  application  of  the  splints. 


Fig.  376.— Pillow  splint. 


In  troublesome  cases  of  this  kind  the  .r-rays  furnish  us  the  most 
valuable  aid,  for  by  the  constant  use  of  the  fluoroscope  during  the 
manipulations  necessary  to  reduction  and  the  application  of  the  splints 
or  other  retention  apparatus,  every  step  of  the  operation  can  be 
controlled.  Recently  the  writer  was  able  to  treat  successfully  in 
this  manner  an  exceedingly  obstinate  case  of  fracture  of  both  bones 
of  the  leg  in  which  slipping  of  the  fragments  and  marked  displacement 
of  the  bones  occurred  no  less  than  six  times  during  the  application 
of  the  plaster  cast.  Each  time  the  deformity  was  recognized  and  cor- 
rected by  use  of  the  fluoroscope,  although  there  was  never  any  appar- 
ent deformity  or  change  in  outline  observed  in  the  soft  parts. 

Almost  any  stiff  material  may  be  used  for  splints;  thin  strips  of 
wood  well  padded  may  be  placed  on  either  side  of  a  broken  arm  or 
leg  and  held  in  position  by  adhesive  strips  and  bandages  (Fig.  377); 
sheets  of  heavy  pasteboard  or  gutta-percha  may  be  softened  in  hot 


814 


FRACTURES 


water  and  moulded  directly  to  the  injured  part  and  secured  by  band- 
ages; or,  best  of  all,  strips  of  crinoline  thoroughly  impregnated  with 
plaster-of-Paris  cream  may  be  employed  in  the  same  manner.  The 
latter  has  the  advantage  of  hardening  quickly  while  the  injured  mem- 
ber is  being  held  in  position.     In  applying  any  splint  or  retention 


Fig.  377. — Side  splints. 

device  the  soft  parts  should  be  protected,  especially  over  the  seat 
of  injury  and  in  the  neighborhood  of  bony  prominences,  by  cotton 
pads.  Care  should  be  taken  to  avoid  undue  pressure,  and  a  portion  of 
the  limb  below  the  seat  of  injury  should  always  be  exposed,  to  enable 
the  surgeon  to  watch  the  condition  of  the  circulation.  In  all  cases  in 
which  extensive  contusions,  edema,  or  ecchymoses  exist,  the  dressings 
should  be  removed  and  the  parts  inspected  frequently  until  all  danger 


Fig.  378. — Fracture-box. 


of  strangulation,  sloughing,  or  gangrene  has  passed.  In  fractures 
of  the  lower  leg  accompanied  by  great  swelling,  severe  bruising,  ecchy- 
mosis,  and  the^formation  of  blebs  on  the  skin,  the  fracture-box  (Fig. 
378)  may  be  used,  for  it  not  only  gives  great  relief  to  the  patient  by 
allowing  the  application  of  wet  dressings,  such  as  a  solution  of  alumin- 


TREATMENT  OF  FRACTURES  IN  GENERAL  815 

ium  acetate  or  lead  and  opium  wash,  but  it  also  enables  the  surgeon 
to  inspect  and  treat  every  part  of  the  injured  leg  without  change 
of  position  or  danger  of  disturbing  the  fragments. 

If  there  is  little  or  no  swelling,  in  simple  fractures  of  the  leg  or 
forearm,  a  cast  of  plaster  of  Paris,  dextrin,  or  starch,  often  can  be  im- 
mediately applied.  This  is  particularly  desirable  if  the  patient  exhibits 
the  premonitory  symptoms  of  delirium  tremens.  For  plaster-of-Paris 
bandages,  the  best  quality  of  dental  plaster  should  be  used.  The 
plaster  must  be  carefully  protected  from  moisture,  both  before  and 
after  impregnating  the  crinoline  rollers. 

To  apply  an  encircling  plaster  cast  to  a  member,  the  fracture 
should  be  properly  reduced  and  the  limb  held  firmly  in  position 
by  an  assistant.  A  thin  layer  of  cotton  or  lint  should  first  be  evenly 
applied  to  the  part.  -This  is  accomplished  best  by  the  use  of  rollers 
made  from  sheet  wadding,  an  exceedingly  soft  and  delicate  material 
which  may  be  obtained  in  any  dry-goods  shop.    After  the  limb  is  evenly 


Fig.  379. — Fenestrated  plaster  dressing.     (Stimson.) 

covered  by  this  material,  several  plaster-of-Paris  rollers  should  be  placed 
in  warm  water  one  at  a  time.  The  plaster  rollers  should  then  be  applied 
to  the  limb,  covering  all  parts  evenly  with  from  four  to  six  or  eight 
layers  of  the  plaster-holding  material.  Where  a  light  cast  is  desir- 
able, thin  strips  of  splint  wood  may  be  inserted  between  the  layers, 
and  less  plaster  applied.  If  the  fracture  is  compound,  or  if  there  exists 
a  wound  of  the  soft  parts  requiring  a  dressing,  a  window  should  be 
left  or  subsequently  cut  in  the  cast,  freely  exposing  the  wounded  area 
which  may  then  be  dressed  without  removing  the  supporting  cast 
(Fig.  379).  This  window  should  be  carefully  filled  in  with  sufficient 
gauze  or  cotton  to  maintain  pressure  over  this  area  equal  to  that 
exerted  on  the  rest  of  the  extremity.  Unless  this  precaution  is  taken, 
the  edema  of  the  exposed  portion  will  be  annoying,  and  there  may 
be  a  tendency  to  displacement  of  the  underlying  bone. 

In  fractures  of  the  long  bones  where  there  is  a  marked  tendency  to 
shortening  of  the  limb  and  overriding  of  the  fragments  by  the  action 


816  FRACTURES 

of  strong  muscles,  this  should  be  overcome  by  the  use  of  some  form  of 
traction  apparatus. 

Open  Treatment  of  Fractures. — In  a  limited  number  of  instances  it 
will  be  necessary  to  obtain  reduction  by  open  operation.  This  should 
only  be  attempted  under  the  most  favorable  circumstances.  It 
requires  special  training,  skilled  assistants  and  a  very  careful  technic, 
as  the  dangers  from  infection  are  greater  here  than  in  almost  any 
other  form  of  operation. 

It  should  be  employed  only  when  a  satisfactory  reduction  cannot 
be  obtained  and  maintained  by  the  closed  method.  The  operation  is 
best  performed  from  the  fifth  to  the  tenth  day,  according  to  the  region 
involved.  It  is  better  to  wait  until  the  body  has  recovered  somewhat 
from  the  original  injury  and  has  had  an  opportunity  to  marshal  the 
forces  of  repair.  It  should  be  performed  before  the  eighteenth  day, 
as  after  that  time  the  reparative  tissue  has  become  sufficiently  organ- 
ized to  make  the  details  of  the  operation  more  difficult  and  accurate 
apposition  less  certain. 

In  a  majority  of  cases  simple  reduction  of  the  displacement  will  be 
all  that  is  necessary,  when  the  reduction  can  be  maintained  by  proper 
splinting  or  by  bandaging  in  a  suitable  position.  If  there  is  any 
question  of  the  fragments  slipping  out  of  place,  however,  it  is  wiser 
to  use  some  internal  means  of  maintaining  the  reduction.  Simple 
suture  of  the  periosteum  with  plain  catgut  may  suffice.  Occasionally 
chromic  catgut,  silk,  linen,  or  wire  will  be  necessary.  Nails,  screws, 
and  bolts  have  their  proper  indications.  The  surest  method  of 
holding  the  fragments  in  place  is  by  the  use  of  metal  plates,  which 
are  securely  fastened  to  the  bone  on  either  side  of  the  line  of  fracture 
by  screws.  The  best  form  of  plate  is  that  made  of  vanadium  steel 
as  devised  by  Sherman.  Plates  made  of  ordinary  steel,  German  silver, 
sheet  aluminum,  or  celluloid  are  also  used.  Machine  screws  are  prefer- 
able to  wood  screws  in  the  shaft  of  a  long  bone,  especially  the  fluted, 
self-tapping  machine  screws  of  Sherman.  In  the  cancellous  portion 
of  bones,  the  wider  flange  of  the  wood  screw  often  gives  a  better  grip. 

The  intramedullary  dowel  has  almost  entirely  gone  out  of  use, 
owing  to  the  difficulty  of  insertion  and  also  of  later  removal  if  this 
should  prove  necessary. 

The  inlay  bone  graft  of  Albee  is  often  indicated.  After  the  frag- 
ments are  properly  reduced  and  the  position  maintained  by  holding 
clamps,  a  segment  of  bone  is  removed  by  a  circular  saw  from  each 
fragment,  the  one  from  the  proximal  end  being  twice  the  length  of 
the  other.  The  long  segment  is  then  moved  up  so  that  its  centre  is 
opposite  the  line  of  fracture.  It  is  fastened  in  place  by  bone  pegs 
made  from  the  shorter  segment.  This  work  must  be  done  very  accur- 
ately and  exactly.  It  is  especially  indicated  in  cases  of  delayed  or 
non-union,  where  a  stimulus  to  bone  formation  is  needed.  The  inlay 
graft  may  be  taken  from  another  bone,  preferably  the  tibia. 

In   all  open  work  on  fractures  the  most  careful  technic  must  be 


TREATMENT  OF  FRACTURES  IN  GENERAL  817 

observed.  Nothing  should  be  allowed  to  enter  the  wound  that  has  been 
touched,  even  by  gloved  hands.  x\ll  the  manipulations  must  be  carried 
out  with  instruments. 

The  after  splinting  should  be  carried  out  with  as  much  care  and  for 
even  a  longer  period  of  time  than  after  a  closed  reduction.  Firm 
union  is  not  obtained  as  quickly  after  an  open  reduction  as  it  is  where 
an  equally  exact  apposition  has  been  obtained  by  the  closed  method. 

Compound  Fractures. — While  deformity  and  loss  of  function  are 
the  common  results  of  unskilful  treatment  in  simple  fractures,  pro- 
longed illness,  loss  of  a  limb,  or  death  from  sepsis,  may  be  the  out- 
come of  unskilful  treatment  in  compound  fractures.  In  addition  to 
the  indications  present  in  the  treatment  of  simple  fractures,  we  must, 
in  the  case  of  compound  fractures,  seek  to  prevent  or  overcome  septic 
infection  of  the  wound.  In  fractures  by  indirect  violence,  when  there 
is  little  injury  to  the  soft  parts,  and  the  opening  leading  to  the  bone 
is  small,  due  to  the  projection  outward  of  a  small  splinter  of  bone 
which  has  not  penetrated  the  clothing,  careful  cleansing  of  the 
surrounding  skin  with  gentle  swabbing  of  the  wound  with  tincture  of 
iodine,  and  the  application  of  a  sterile  dressing  are  recommended  by  most 
surgeons,  in  the  hope  that  infection  has  not  taken  place,  and  that  the 
injury  may  thereby  be  quickly  converted  into  a  simple  fracture.  In 
fractures  by  direct  violence  or  where  the  end  of  the  bone  has  penetrated 
the  skin  to  a  greater  extent  or  come  in  contact  with  the  clothing  or 
other  unsterile  material,  it  is  safer  to  explore  and  drain  the  region  of 
the  fracture.  This  should  be  done  under  general  anesthesia;  the 
limb  should  be  shaved,  scrubbed,  and  otherwise  prepared  as  for  a 
strictly  aseptic  operation.  The  wound  should  then  be  sufficiently 
enlarged  to  allow  thorough  inspection  of  the  line  of  fracture;  all 
evidently  devitalized  tissue  should  next  be  removed  and  the  cavity 
swabbed  with  tincture  of  iodine.  A  1  to  50  solution  of  formalin  or  hydro- 
gen peroxide  is  often  of  value  in  wounds  which  are  already  inflamed 
and  foul,  the  latter  serving  also  to  arrest  troublesome  oozing  of  blood. 
The  wound  can  then  be  partly  closed,  thorough  drainage  being  pro- 
vided by  gauze  packing  or  rubber  tubes,  a  sterile  dressing  and  a  suit- 
able retaining  apparatus  applied.  When  there  is  a  tendency  to  separa- 
tion of  the  fragments  they  sometimes  can  be  held  together  by  a  suture 
of  chromicized  catgut  but  no  formal  operation  to  obtain  reduction, 
which  necessitates  baring  additional  surfaces  of  bone  or  opening  new 
routes  for  spread  of  infection,  should  be  attempted  in  the  early  days 
of  a  compound  fracture.  The  surgeon  must  be  satisfied  with  the 
establishment  of  free  drainage  with  as  little  added  trauma  as  possible. 
The  fenestrated  plaster  cast  or  wire  splint,  allowing  free  access  to 
the  wound  and  drainage  openings,  will  be  found  useful  if  there  is 
reason  to  believe  that  the  wound  is  badly  infected  and  will  require  an 
early  change  of  dressing.  In  cases  in  which  the  wound  is  small  and  in 
which  little  or  no  infection  is  suspected,  a  circular  plaster  cast  may 
be  applied,  and  the  dressings  allowed  to  remain  in  place  for  several 
52 


818  FRACTURES 

weeks.  If  it  is  found  impossible  to  maintain  a  satisfactory  reduction 
by  careful  splinting  and  traction,  it  is  often  wise  to  operate  later, 
obtain  a  proper  reduction  and  maintain  it  by  suture  or  plating.  This, 
however,  should  not  be  done  until  the  infection  has  become  limited 
and  the  resisting  forces  of  the  tissues  well  organized.  It  is  often  pos- 
sible to  approach  the  site  of  fracture  through  tissue  uninjured  by  the 
original  trauma,  apply  the  plate  and  close  the  wound  completely,  leaving 
the  original  wound  as  a  drainage  route.  Plates  and  screws  used  in 
such  compound  fractures  should  always  be  removed  after  there  is 
sufficient  union  to  make  their  further  presence  unnecessary. 

In  cases  in  which  the  infection  spreads  widely  and  is  not  controlled 
by   the   ordinary   methods,   wider   incisions   and   freer  drainage   may 


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2 

Fig.  380. — Instruments  used  in  operative  treatment  of  fractures.  1,  sharp  hook; 
2  and  3,  Lane  elevators;  4,  Lane  holding  clamps;  5,  6,  and  7,  Lambotte  holding  clamps; 
8,  Lane  saw  edged  elevator;    9,  drill;    10,  Gerster  turnbuckle;    11.  elevator. 

sometimes  be  successful.  Under  these  conditions  the  continuous  warm 
bath  has  often  proved  useful,  the  solution  used  being  mercuric  chloride 
(-1  to  100,000)  or  carbolic  acid  (1  to  1000).  Amputation  should  be 
promptly  resorted  to  in  cases  in  which  an  acute  osteomyelitis  develops, 
and  in  which  the  life  of  the  patient  is  in  danger  from  general  sepsis. 

Delayed  union  or  non-union  generally  is  the  result  of  faulty  position, 
the  interposition  of  a  layer  of  muscle  or  other  soft  tissue  between  the 
fragments  or  infection  in  compound  cases.  It  occasionally  happens 
that  the  reparative  powers  of  the  individual  are  so  reduced  that  callous 
formation  does  not  take  place  even  if  the  position  of  the  bones  is 
correct.  Massage,  with  moderate  irritation  of  the  fragments  by  fric- 
tion, will  often  excite  an  inflammatory  reaction  and  stimulate  repair. 
Bier  and  Schmieden,  believing  that  callous  formation  bears  a  direct 


TREATMEXT  OF  FRACTURES  IN  GENERAL 


819 


relation  to  the  amount  of  extravasated  bl 1.  advise  the   injection 

between  and  about  the  fragments  of  from  30  to  40  c.c.  of  fresh  venous 
blood  drawn  from  the  patient's  arm.    This  to  be  repeated  at  intervals 


FlG  3si_ii  12  and  13,  Sherman  vanadium  steel  plates,  straight:  1-4,  same, 
amded-  15  and"  16.  Sherman  bolts;  17,  IS,  and  19,  Sherman  fluted  machine  screws, 
S-tappin*:  20,  round  head  wood  screw;  21,  flat  head  wood  screw:  22.  machine  screw; 
23,  Sherman-Pierce  combination  screw  holder  and  driver;  24,  screw  driver  alone. 

of  ten  days  or  two  weeks.  If  failure  then  persists  open  operation,  fresh- 
ening the  ends  of  the  bone  and  correct  apposition,  maintained,  if 
necessary,  by  sutures,  nails,  medullary  dowels,  inlay  graft  or  metal 
plates  is  the  treatment  to  be  followed. 


820  FRACTURES 

Visceral  injuries,  caused  by  fragments  of  bone  penetrating  the 
cranial,  thoracic,  or  abdominal  cavities,  lacerating  or  causing  pressure 
on  the  contained  organs,  call  for  immediate  surgical  relief. 

Injuries  to  adjacent  nerves,  bloodvessels,  or  ligaments  must  be  sought 
for  and  repaired  early  when  necessary. 

Massage  is  often  of  the  greatest  value  in  developing  an  increase 
in  the  circulation  of  the  injured  part,  and  thereby  preventing  marked 
atrophy  of  the  muscles  and  causing  rapid  absorption  of  the  inflam- 
matory exudates.  Its  use  also  favors  nature's  processes  of  repair 
and  prevents  stiffness  of  the  joints  and  tendons.  It  may  be  employed 
as  soon  as  the  limb  can  be  handled  without  displacing  the  fragments, 
and  should  be  applied  regularly  every  day. 

Local  heat  undoubtedly  aids  in  the  late  repair.  Daily  baking  (dry 
heat  250°  to  300°  F.),  soaking  the  part  in  hot  water  for  fifteen  or 
twenty  minutes  several  times  a  day,  or  the  use  of  an  electric  pad  are 
all  satisfactory  methods  of  obtaining  local  heat. 

Passive  motion,  unless  carried  out  with  extreme  gentleness,  may 
do  far  more  harm  than  good.  If  carried  beyond  the  point  of  moderate 
discomfort  the  added  trauma  is  followed  by  a  reaction  on  the  part  of 
the  tissues  which  only  adds  to  the  impairment  of  function  and  delays 
complete  recovery.  Only  when  actual  ankylosis  exists  can  "  breaking 
up  adhesions"  under  an  anesthetic  be  countenanced. 

Active  motion,  on  the  other  hand,  should  be  encouraged  from  the 
earliest  period.  Any  movement  of  the  adjacent  joints  which  does  not 
endanger  the  position  of  the  fragments  is  allowed  and  urged  after  the 
first  twenty-four  hours.  For  example,  after  a  Colles'  fracture,  the 
patient  should  be  instructed  to  use  the  fingers,  elbow,  and  shoulder 
frequently  up  to  the  point  of  pain  or  overtire.  The  wrist-joint,  how- 
ever, must  be  immobilized  until  actual  bony  union  is  well  under  way. 

The  general  health  of  the  individual  should  also  receive  attention, 
and  phosphate  of  calcium  or  the  syrup  of  hypophosphites  should  be 
given  if  union  is  apparently  delayed  from  lowered  vitality. 

In  the  aged  it  must  be  remembered  that  long  continuance  of  the 
recumbent  position  favors  hypostatic  congestion  and  pneumonia, 
and  an  effort  should  be  made  to  employ  apparatus  which  will  allow 
the  patient  to  assume  a  sitting  posture  as  soon  as  possible.  This  is 
especially  important  if  there  is  a  chronic  bronchitis  or  emphysema 
present. 

FRACTURES  OF  THE  SKULL. 

See  Chapter  XV. 


FRACTURES  OF  THE  FACE  BONES. 

Nasal  Bones. — Fractures  of  the  nasal  bones  are  usually  due  to  direct 
violence.    The  fragments  are  generally  displaced  laterally  or  are  driven 


FRACTURES  OF  THE  FACE  BOXES  821 

inward.     The  line  of  fracture  may  extend  to  the  superior  maxilla  or 

lachrymal  hones,  and  involve  the  tear  duct. 

Symptoms.- -The  symptoms  are  deformity,  swelling,  and  ecchymosis 
of  the  overlying  soft  parts,  and  bleeding  from  the  nose.  Mobility  and 
crepitus  may  be  obtained  by  palpation;  obstruction  to  nasal  respira- 
tion is  occasionally  present  from  deflection  of  the  cartilaginous  septum 
or  swelling  of  the  mucous  membrane.  Efforts  to  blow  the  nose  may 
result  in  extensive  swelling  of  the  surrounding  parts  and  emphysema. 

Treatment. — The  treatment  should  consist  in  early  replacement  of 
the  fragments,  as  the  tendency  to  rapid  union  is  marked.  If  consid- 
erable deformity  exists,  an  anesthetic  should  be  administered  and  the 
fragments  moulded  into  place  by  the  fingers  alone  or  by  the  fingers 
aided  by  some  blunt  instrument  introduced  within  the  nostril.  Long 
curved  forceps  with  rubber  tubing  over  each  blade  are  very  useful  in 
handling  the  fragments.  With  one  blade  in  the  nostril  and  the  other 
outside  a  firm  grip  can  be  obtained  and  the  pieces  moulded  into  shape. 

Displacements  of  the  septum  can  be  corrected  by  use  of  the  Adam- 
forceps  (Fig.  382).     If  the  fragments  are  properly  reduced  they  will 


Fig.  382. — Adams  forceps. 

stay  in  position  unless  disturbed.  Pads  and  adhesive  plaster  are  of 
very  doubtful  value,  except  to  call  attention  to  the  injury.  Gutta- 
percha plates  moulded  to  the  nose  may  be  of  service  to  protect  against 
further  injury.  Packing  the  nose  may  be  necessary  to  arrest  hemor- 
rhage, but  is  rarely  necessary  to  support  the  fragments. 

Malar  Bone  and  Zygoma. — Fractures  of  the  malar  bone  and  zygoma 
are  rare,  generally  due  to  direct  violence,  and  are  often  accompanied 
by  fracture  of  the  superior  maxilla.  They  are  recognized  by  the 
deformity,  localized  tenderness,  mobility,  and  crepitus.  In  fractures 
of  the  zygoma  the  bone  is  usually  displaced,  and  there  are  pain  and 
difficulty  in  opening  and  closing,  the  mouth,  owing  to  the  traction  of 
the  masseter  muscle  and  the  contact  of  the  depressed  fragment  of  bone 
with  the  coronoid  process  or  temporal  muscle. 

Replacement  under  these  conditions  may  be  difficult,  and  accom- 
plished only  by  an  external  incision  and  drawing  the  fragment  forward 
with  a  hook.  The  hook  can  be  introduced  through  a  very  small 
incision  and  depression  and  rotation  easily  overcome. 

Opening  the  antrum  from  within  the  mouth  and  pressing  the  bone 
into  place  is  a  more  risky  procedure  and  it  may  lead  to  antrum  infec- 


822  FRACTURES 

tion.  Sometimes,  however,  these  procedures  are  unnecessary,  as  a 
sufficiently  accurate  replacement  can  be  effected  by  manipulation. 

Superior  Maxilla. — Fractures  of  the  superior  maxilla  are  practic- 
ally always  the  result  of  direct  violence.  The  processes  are  more  often 
involved  than  the  body  of  the  bone;  the  fracture  may  involve  the 
antrum,  and  is  generally  associated  with  other  injuries. 

Symptoms. — The  symptoms  are  pain  on  motion,  bleeding  from  the 
mouth  or  nose,  bruising  and  ecchymosis  of  cheek  and  lips,  abnormal 
mobility,  and  crepitus.  Emphysema  may  follow  an  attempt  to  blow 
the  nose. 

Treatment. — The  broken  fragments  should  be  replaced  and  held 
in  position  by  wiring  the  teeth,  by  an  interdental  splint,  or  by  direct 
suture  with  chromicized  catgut  or  silver  wire.  If  there  is  a  tendency 
to  displacement  of  the  fragments,  the  jaw  should  be  kept  closed  by  a 
four-tailed  bandange  (Fig.  61)  and  liquid  food  only  administered 
through  a  tube.  When  the  mucous  membrane  of  the  mouth  is  torn  in 
these  and  in  fractures  of  the  lower  jaw  infection  is  always  present, 
giving  rise  to  a  foul,  purulent  discharge  and  an  extremely  offensive 
odor  to  the  breath.  To  minimize  the  discomfort  arising  from  this,  the 
mouth  should  be  frequently  cleansed  with  hydrogen  peroxide  and  other 
astringent  and  antiseptic  solutions. 

Lower  Jaw. — Fractures  of  the  lower  jaw  are  comparatively  common 
in  males  of  middle  age,  generally  due  to  blows  or  falls;  the  commonest 
location  of  the  break  is  at  or  near  the  canine  tooth.  Two  or  more 
fractures  may  occur.  Fractures  limited  to  the  alveolar  process  or 
of  the  condyloid  or  coronoid  processes  are  rare.  These  fractures,  when 
involving  the  horizontal  ramus,  are  probably  always  compound, 
communicating  with  the  oral  cavity. 

Symptoms. — In  s'ngle  fracture  of  the  horizontal  ramus  the  deform- 
ity is  slight,  easily  appreciated,  and  readily  reduced.  In  fracture 
involving  the  coronoid  process  the  upper  fragment  is  drawn  upward 
by  the  temporal  muscle.  In  fractures  of  the  condyloid  process  there 
are  pain  on  moving  the  jaw,  a  lateral  dev'ation  of  the  chin  toward  the 
affected  side,  and  displacement  of  the  condyle  upward  and  forward 
by  traction  of  the  external  pterygoid.  In  double  fracture,  on  either 
side  of  the  symphysis,  the  intervening  fragment  is  drawn  backward 
by  the  action  of  the  hyoid  muscles.  The  horizontal  ramus  is  so  easily 
palpated  through  the  mouth  that  diagnosis  in  fractures  of  this  part  of 
the  bone  presents  no  difficulties.  In  fractures  above  the  angle  the 
diagnosis  must  be  made  from  the  characteristic  deformity  and  finding 
a  point  of  localized  tenderness,  abnormal  mobility,  and  crepitus. 

Treatment. — The  treatment  of  a  single  transverse  fracture  through 
the  horizontal  ramus  is  comparatively  simple.  In  many  cases  all  that 
is  necessary  is  to  keep  the  part  at  rest  after  reduction  of  the  deform- 
ity. This  is  accomplished  best  by  making  an  interdental  splint  of 
gutta-percha  (Fig.  383),  and  keeping  the  jaws  closed  upon  it  by  means 
of  a  four-tailed  bandage.     If  there  is  a  marked  tendency  to  displace- 


FRACTURES  OF  THE  BOXES  OF  THE  TRUNK  823 

nu'iit  of  the  fragments  owing  to  obliquity  of  the  line  of  fracture  or  the 
presence  of  two  or  more  fractures,  the  fragments  can  often  be  firmly 
held  by  wiring  the  teeth  together  on  either  side  of  the  break,  or,  better, 
by  direct  union  of  the  fragments  with  silver  wire  or  chromicized  catgut. 

As  in  fracture-  of  the  upper  jaw,  especial  eare  should  he  taken  to  keep 
the  mouth  disinfected.  Not  infrequently  a  localized  osteomyelitis 
follows  fracture  of  the  jaws,  requiring  subsequent  operation. 


Fig.  383.— Gunning's  interdental  splint,  with  opening  for  introducing  food. 

FRACTURES  OF  THE  BONES  OF  THE  TRUNK. 

Sternum.— Fractures  of  the  sternum  are  comparatively  rare.  They 
occur  mostly  in  middle-aged  males,  from  direct  violence  or  severe 
crushing  injuries,  and  are  generally  accompanied  by  fractures  of  the 
ribs.  The  line  of  fracture  is  usually  transverse,  and  its  commonest 
seat  is  at  the  junction  of  the  manubrium  with  the  body  of  the  bone 
opposite  the  second  intercostal  space.  As  union  of  these  two  portions 
of  the  bone  is  often  delayed  until  old  age,  this  injury  is  often  a  separa- 
tion of  the  two  portions  rather  than  a  fracture.  Fractures  imme- 
diately above  or  below  this  point  are  more  common  than  fracture  at 
the  lower  part  of  the  bone.  Separations  of  the  ensiform  are  occasion- 
ally encountered. 

In  fracture  or  separation  at  the  junction  of  the  manubrium  with 
the  body  of  the  bone  the  lower  fragment  generally  lies  above  and 
sometimes  overrides  the  upper. 

Longitudinal  fractures  have  been  observed.  Compound  and  com- 
minuted fractures  are  exceedingly  rare  except  in  connection  with 
gunshot  wounds.  In  severe  crushing  traumata  hemorrhage  into  the 
mediastinum  and  lesions  of  the  thoracic  viscera  may  complicate  the 
injury. 

Diagnosis. — The  diagnosis  of  this  condition  is  comparatively  easy 
in  the  absence  of  marked  swelling  of  the  overlying  soft  parts,  the 
signs  being  irregularity  in  the  outline  of  the  bone,  localized  tender- 
ness, abnormal  mobility,  and  crepitus.  Spontaneous  reduction  fre- 
quently occurs.  In  these  cases  the  only  treatment  necessary  is  the 
application  of  a  firm  binder,  adhesive  strips,  or  a  plaster  jacket.  Y\  hen 
there  is  little  or  no  tendency  to  displacement  and  no  pain,  simple  rest 
in  bed  is  all  that  is  required. 


82  \  FRACTURES 

Treatment. — If  marked  deformity  exists  from  overriding  of  the 
fragments,  reduction  may  offer  difficulties.  It  is  generally  accom- 
plished by  bending  the  body  backward  and  exerting  pressure  over 
the  projecting  fragment  while  the  patient  takes  a  deep  breath.  If  this 
does  not  succeed,  reduction  generally  can  be  effected  by  an  open 
operation  under  anesthesia,  and  replacement  of  the  fragments  by  an 
elevator  or  hook,  or  by  screwing  a  gimlet  into  the  depressed  fragment 
and  drawing  it  into  place. 

Ribs  and  Costal  Cartilages. — Fractures  of  the  ribs  and  costal  carti- 
are  of  frequent  occurrence.  They  are  caused  by  direct  violence, 
as  ;i  blow  or  fall  upon  the  thorax;  by  indirect  violence,  as  in  a  crush- 
ing injury;  by  muscular  action,  as  in  coughing  or  sneezing.  The 
middle  ribs  are  more  frequently  fractured  than  those  nearer  the 
upper  and  lower  boundaries  of  the  thorax.  The  injury  may  be  limited 
to  ;i  -ingle  rib,  or  many  may  be  involved  in  the  trauma.  Under  ordi- 
nary conditions  the  point  of  fracture  is  more  often  near  the  middle  of 
the  lone,  and  anterior  to  this  point  rather  than  posterior.  Fracture 
near  the  bony  and  cartilaginous  junction  is  not  uncommon,  and 
fracture  of  the  costal  cartilage  is  occasionally  observed. 

When  a  single  rib  is  fractured,  there  is,  as  a  rule,  no  displacement, 
a-  the  muscular  and  fascial  layers  serve  to  hold  it  in  place.  When, 
however,  several  ribs  are  broken,  these  attachments  are  often  torn, 
and  there  may  be  displacement  with  overriding.  When  the  trauma 
i-  -•  were,  the  fragments  may  penetrate  the  pleura  or  lung,  giving  rise 
to  pneumothorax,  collapse  of  the  lung,  hemoptysis,  and  subcutaneous 
emphysema.  In  injuries  of  this  character  the  pericardium  and  heart 
may  also  be  wounded.  Hemothorax  from  a  wound  of  an  intercostal 
artery  may  occur. 

Diagnosis. — The  diagnosis  of  fracture  of  a  rib  is  generally  to  be 
inferred  if.  after  a  blow  or  fall  upon  the  chest,  there  is  a  point  of  local- 
ized tenderness,  with  acute  pain  on  inspiration,  coughing,  or  sneezing. 
Crepitus  may  often  be  elicited  by  palpation  or  heard  with  the  stetho- 
scope. When  several  ribs  are  fractured,  abnormal  mobility  and 
crepitus  are  easily  obtained  by  palpating  the  region  with  the  flat  hand. 
Fractures  of  the  ribs  are  rarely  compound,  except  those  produced  by 
gunshot  or  other  penetrating  injuries. 

Prognosis. — The  prognosis  depends  upon  the  visceral  trauma.  In 
a  simple  fracture  of  one  or  more  ribs  without  involvement  of  the 
pleura  recovery  is  rapid  and  uneventful.  If  the  lung  or  other  important 
structures  are  involved,  the  prognosis  is  necessarily  more  grave, 
depending  upon  the  extent  and  character  of  the  visceral  involvement. 

Treatment— The  treatment  consists  in  rest,  limitation  of  the  move- 
ments of  the  chest-wall,  and  measures  addressed  to  the  pleural  and 
pericardial  complications  if  these  are  present.  It  is  rarely  necessary 
to  reduce  a  fracture  of  a  rib,  as  there  is  seldom  marked  displacement. 
If,  however,  a  fragment  is  driven  inward  and  remains  a  source  of  irri- 
tation to  the  pleura  or  lung,  it  should  be  properly  reduced.     When 


FRACTURES  OF   THE  BONES  OF   THE   TRUNK  825 

this  is  not  easily  accomplished  by  manipulation  and  inspiratory 
efforts  of  the  patient,  replacement  by  a  hook  or  elevator  through  an 
open  wound  may  be  necessary. 

Limitation  of  the  thoracic  movements  will  often  promptly  relieve 
tlie  pain.  This  is  accomplished  best  by  a  snugly  fitting  binder  or  by 
the  application  of  adhesive  plaster  straps,  always  during  expiration. 
The  plaster  straps  should  completely  encircle  the  chest  in  order  to 
obtain  the  proper  immobilization. 

The  Pelvis. — Fractures  of  the  pelvis  may  occur  from  crushing 
injuries,  from  falls  from  a  height  upon  the  iliac  crest,  trochanter, 
sacrum,  pubic  symphysis,  or  feet;  or  from  blows  received  in  this 
region  by  some  heavy  object.  These  fractures  are  often  accompanied 
by  injury  to  the  bloodvessels  or  some  of  the  pelvic  or  abdominal  viscera. 

The-e  fractures  may  be  conveniently  divided  into  two  groups: 
those  which  involve  the  integrity  of  the  pelvic  brim,  and  those  which 
are  limited  to  a  part  remote  from  the  true  pelvis.  The  former  are  far 
more  serious  in  their  results  than  the  latter.  In  fractures  of  the  pelvic 
ring  the  commonest  seat  is  through  the  pubic  rami,  both  horizontal 
and  descending  rami  being  often  involved,  as  these  are  the  weakest 
part-  of  the  bony  pelvis.  Occasionally  the  fracture  is  bilateral,  the 
symphysis  being  entirely  separated  and  driven  backward  into  the 
pelvic  cavity.  Vertical  fractures  of  the  ilium  extending  into  the  true 
pelvis  often  accompany  fractures  of  the  pubic  arch.  The  acetabulum 
may  be  fissured  by  a  fall  upon  the  feet  or  trochanter,  its  rim  broken, 
or  the  head  of  the  femur  may  be  driven  through  it>  walls  into  the 
pelvis.  Horizontal  and  vertical  fractures  of  the  sacrum  occur  in 
connection  with  other  fractures  of  the  pelvis,  and  a  separation  of  the 
sacro-iliac  joint  may  be  produced  under  similar  conditions.  All  of 
these  fracture-  involving  the  pelvic  brim  are  likely  to  be  associated  with 
visceral  injury.  Those  most  frequently  found  are  wounds  of  the 
urethra,  rupture  of  the  bladder,  tears  of  the  rectum,  injuries  to  the 
iliac  ves.-els,  and  lacerations  of  the  intrapelvic  portion  of  the  ureter. 

Fractures  of  the  iliac  crest,  coccyx,  or  other  parts  not  involving  the 
integrity  of  the  pelvic  brim,  occur,  but  are  not  generally  associated 
with  injury  of  the  viscera  or  vessels. 

Diagnosis. — The  diagnosis  is  usually  easy.  There  is  a  history  of 
severe  injury,  followed  by  pain  in  the  region  of  the  pelvis,  which  is 
increased  by  any  movement  of  the  trunk  or  legs.  Pressure  over  the 
iliac  crests  toward  the  median  line  will  always  elicit  pain  unless  the 
fracture  is  limited  to  the  coccyx,  descending  rami,  or  tuberosity  of  the 
ischium.  Careful  palpation  of  the  pubic  arch,  iliac  crests,  sacral 
region,  and  of  the  interior  of  the  pelvis  by  the  rectum  or  vagina,  will 
often  serve  to  locate  the  seat  of  fracture.  In  fissures  of  the  acetabulum 
the  only  symptom  may  be  pain  in  the  joint  following  a  fall  upon  the 
feet  or  trochanter.  This  may  be  rendered  acute  by  a  blow  upon  the 
foot  or  knee.  Fractures  of  the  rim  of  the  acetabulum  are  generally 
accompanied  by  dislocation  of  the  head  of  the  femur  upward,  which 


826  FRACTURES 

is  easily  reduced  by  traction  but  readily  recurs.  When  the  head  is 
driven  into  the  pelvis,  there  is  flattening  of  the  hip,  and  the  head  of 
the  bone  may  sometimes  be  felt  by  rectal  examination.  In  severe 
cases,  when  there  is  a  complicating  visceral  injury,  the  shock  is  often 
so  great  as  to  mask  other  symptoms.  In  urethral  injuries  we  may 
have  retention  or  extravasation  of  urine.  Hematuria  is  present  in 
wounds  of  the  bladder  or  ureter.  In  extensive  intraperitoneal  wounds 
of  the  bladder  the  viscus  may  be  empty,  the  catheter  withdrawing 
only  a  small  quantity  of  blood.  Intermittent  hematuria  suggests  a 
wound  of  the  ureter.  Rectal  bleeding  is  present  in  wounds  of  that 
organ  or  the  sigmoid  colon.  Wounds  of  the  iliac  vessels  are  indicated 
by  the  gradual  development  of  a  semisolid  retroperitoneal  pelvic  tumor 
or  by  pallor,  cold  extremities,  weak  pulse,  and  other  evidences  of  shock, 
when  the  hemorrhage  is  within  the  peritoneal  cavity. 

Treatment. — The  treatment  in  uncomplicated  cases  consists  in  the 
reduction  of  any  deformity  and  the  application  of  a  dressing  to  secure 
immobility  of  the  parts.  The  employment  of  a  stout  pelvic  binder, 
or  double  plaster  spica,  is  generally  sufficient.  Semiflexion  of  the 
thighs,  the  legs  resting  on  one  or  two  pillows  placed  under  the  knees, 
is  a  comfortable  position  for  the  patient.  Tying  the  legs  together 
may  be  necessary  if  the  fragments  are  loose  and  easily  displaced.  If 
there  is  evidence  of  vesical  injury  or  severe  hemorrhage,  laparotomy 
should  be  performed  to  locate  the  seat  of  the  hematoma  and  to  repair 
any  intraperitoneal  injury,  after  which  the  peritoneum  should  be 
closed  and  the  prevesical  space  opened,  clots  removed,  vessels  secured, 
bladder  wound  repaired,  and  the  displaced  fragments  of  bone,  if 
present,  reduced  and  held  by  sutures.  Generous  drainage  should  be 
employed  in  the  suprapubic  wound,  and  the  bladder  drained  by  a 
perineal  tube. 

In  fractures  of  the  tuberosities  of  the  ischium,  sacrum,  or  coccyx, 
no  treatment  is  required  other  than  rest,  immobility,  and  the  use 
of  air  cushions  to  prevent  pressure  on  the  loose  fragments.  In  fracture 
of  the  rim  of  the  acetabulum,  extension,  as  in  fractures  of  the  femur, 
may  serve  to  keep  the  head  of  the  bone  in  the  socket,  although  the 
prognosis  is  not  favorable. 

FRACTURES    OF    THE    BONES    OF    THE    UPPER   EXTREMITIES. 

Scapula. — Fractures  of  the  scapula  are  comparatively  rare.  The 
portion  of  the  bone  most  frequently  broken  is  the  acromion  process; 
next  in  frequency  come  the  body  and  spine;  fractures  of  the  neck, 
coracoid  process,  and  glenoid  fossa  are  rare. 

Acromion. — This  fracture  is  generally  transverse  and  situated  just 
in  front  of  the  acromioclavicular  articulation.  It  is  due  to  a  fall 
or  blow  on  the  shoulder,  elbow,  or  hand,  or  to  direct  violence  on  the 
tip  of  the  shoulder.  Traumatic  separation  may  take  place  at  the 
epiphyseal  line  at  any  age,  and  it  should  be  remembered  that  a  failure 


FRACTURES  OF  BONES  OF  THE   UPPER   EXTREMITIES     827 

of  union  of  the  epiphysis  may  occur  which  may  lead  to  an  error  of 
diagnosis  in  a  contusion  of  this  region. 

The  diagnosis  is  usually  made  by  observing  a  slight  flattening  of 
the  shoulder,  localized  tenderness,  and  irregularity  of  outline  on 
passing  the  finger  along  the  edges  of  the  bone,  crepitus  and  abnormal 
mobility  on  raising  the  arm  and  shoulder.  Voluntary  abduction  of 
the  arm  is  painful  and  often  impossible. 

Bony  union  occurs  only  when  the  fragments  are  accurately  replaced. 
This  is  often  difficult  to  accomplish,  and  in  the  majority  of  instances 
the  union  is  fibrous. 

Treatment. — The  treatment  consists  in  the  application  of  a  dressing 
which  pushes  the  humerus  wTell  upward  and  outward.  The  use  of 
Moore's  figure-of-eight  bandage  from  the  elbow  to  the  opposite 
shoulder  (Figs.  384  -and  385)  perfectly  fulfils  this  indication.  If  this 
fails  to  maintain  close  and  accurate  apposition  of  the  fragments  the 
site  of  fracture  should  be  exposed  by  incision,  and  the  bones  united 
by  twro  sutures  of  silk  or  chromic  catgut.  A  metal  plate  may  be 
applied  to  the  dorsal  surface  of  the  acromion  and  spine.  This  should 
be  removed  later  because  of  its  subcutaneous  position. 

Body  and  Spine. — Fractures  of  the  body  of  the  bone. are  generally 
due  to  direct  violence.  The  line  of  fracture  is  commonly  transverse; 
it  may,  however,  be  oblique  or  irregular,  and  occasionally  assumes  a 
longitudinal  direction  extending  through  the  spine.  Fractures  of  the 
supraspinous  region  are  very  rare.  Isolated  fracture  of  the  spine  is 
uncommon. 

Diagnosis. — The  diagnosis  is  established  by.  direct  palpation  and  by 
movements  of  the  arm,  revealing  points  of  tenderness,  irregularities 
in  outline,  mobility,  and  crepitus. 

Treatment. — The  treatment  consists  in  reduction  by  manipulation 
and  movements  of  the  arm,  and  retention  by  the  application  of  adhesive 
plaster  straps  or  a  snugly  fitting  binder  and  sling,  as  seen  in  Figs.  59 
and  60. 

Neck  and  Glenoid. — Fractures  of  the  neck  and  glenoid  are  exceed- 
ingly rare.  In  the  former  the  line  of  fracture  may  include  the  coracoid 
process  or  lie  external  to  it;  in  the  latter  the  fracture  may  be  stellate. 
Epiphyseal  separation  of  the  neck,  including  the  coracoid,  is  possible 
before  the  fourteenth  year. 

Diagnosis. — In  fractures  of  the  neck  the  signs  are  those  of  a  sub- 
glenoid dislocation:  flattening  of  the  shoulder,  prominence  of  the 
acromion,  and  the  presence  of  the  head  in  the  axilla.  Reduction  is 
easily  accomplished  by  raising  the  humerus,  but  the  deformity  is  at 
once  reproduced  when  the  support  is  removed.  These  movements 
give  rise  to  crepitus. 

Treatment. — The  treatment  consists  in  reduction,  which  is  easy,  and 
retention  of  the  fragments,  which  is  difficult  to  accomplish.  The 
application  of  Moore's  figure-of-eight  bandage  (Figs.  384  and  385),  or 
the  sling  and  binder  dressing,  will  be  found  useful.    The  writer  on  one 


828 


FRACTURES 


occasion  obtained  a  satisfactory  result  by  the  immediate  application 
of  a  plaster-of-Paris  spica  extending  from  the  shoulder  to  the  hand, 
the  elbow  Hexed  across  the  chest,  and  the  humerus  being  pushed  firmly 
upward  and  held  in  this  position  until  the  plaster  hardened. 

Coracoid. — Fractures  of  the  coracoid  process  are  generally  due  to 
direct  violence,  and  are  often  associated  with  fracture  of  the  clavicle 
or  ribs.  If  the  ligamentous  attachments  are  ruptured,  there  may  be 
a  separation  by  action  of  the  biceps,  coracobrachialis,  and  pectoralis 
minor  muscles. 


Fig.  38-1. — Moore's  dressing  for  frac- 
tured clavicle.     Front  view. 


Fig.  385. — Moore's  dressing  for  fractured 
clavicle.     Rear  view. 


Diagnosis. — The  signs  are  pain  on  motion  and  localized  tenderness; 
crepitus  may  be  felt  if  the  fragments  are  not  wridely  separated.  Union 
is  generally  fibrous,  but  without  functional  disturbance. 

Treatment. — The  treatment  should  consist  in  the  application  of  a 
Velpeau  bandage  (Fig.  53).  If  this  fails  to  maintain  sufficiently  good 
apposition  it  may  be  necessary  to  expose  the  site  of  fracture  and  hold 
the  fragments  together  by  a  long  screw. 

Clavicle. — The  clavicle  is  fractured  more  frequently  than  any  other 
bone  in  the  body.  By  far  the  larger  number  of  cases  occur  in  child- 
hood, although  it  is  by  no  means  infrequent  in  later  life  The  seat  of 
fracture  is  commonest  at  the  outer  portion  of  the  middle  third,  where 
the  line  is  usually  oblique.    Next  in  frequency  fractures  occur  in  the 


FRACTURES  OF  BONES  OF  THE   UPPER  EXTREMITIES     829 

outer  third.  Here  they  are  apt  to  be  transverse,  with  little  or  no  dis- 
placement except  at  the  outer  end,  where  displacement  may  be  marked. 
Fractures  near  the  sternal  end  are  rare,  as  is  a  separation  of  the  epiphy- 
sis. The  commonest  cause  of  this  fracture  is  indirect  violence,  as  ;i 
fall  on  the  shoulder,  elbow,  or  outstretched  hand,  the  muscles  being 
rigid  (an  application  of  force  which  in  later  life  frequently  results  in 
a  dislocation  of  the  shoulder).  Direct  violence  is  responsible  for  a 
considerable  number  of  these  fractures,  and  muscular  action  has  been 
recorded  in  a  few.  Indirect  violence  produces  the  fracture  by  exag- 
gerating the  normal  curves  of  the  bone,  which  results  in  the  oblique 
direction  of  the  break.  The  inner  fragment  is  pulled  upward  by  the 
action  of  the  sternomastoid  muscle;  the  outer  fragment  falls  down- 
ward and  forward  by  the  weight  of  the  unsupported  shoulder. 

Complications. — Complication  in  this  fracture  are  rare.  The  fracture 
may  be  compound,  double  (generally  in  the  middle  third),  or  com- 
minuted. Occasionally  the  fragments  are  driven  inward,  injuring 
the  trunks  of  the  brachial  plexus  or  subclavian  vessels.  In  the  former 
condition  a  more  or  less  complete  and  persistent  paralysis  of  motion 
or  sensation  may  result  from  pressure  or  secondary  neuritis;  in  the 
latter,  extensive  hematomata  or  arteriovenous  aneurism  may  occur, 
requiring  immediate  or  remote  surgical  treatment. 

Diagnosis. — The  diagnosis  of  fracture  of  the  clavicle  is  usually  easy. 
The  patient  sits  or  stands  with  the  head  inclined  toward  the  injured 
side,  the  shoulder  lowered,  and  the  elbow  supported  by  the  sound 
hand  or  resting  upon  the  knee.  All  movements  of  the  shoulder  are 
painful.  On  palpation  bony  irregularity,  localized  tenderness,  and 
crepitus  can  be  readily  appreciated.  In  transverse  fractures  of  the 
outer  third  without  displacement  localized  tenderness  and  pain  on 
motion  of  the  shoulder  may  be  the  only  signs.  In  a  fracture  of  the 
inner  third  the  deformity  may  resemble  a  dislocation  of  the  sternal 
extremity. 

Prognosis. — The  prognosis  in  fracture  of  the  clavicle  is  usually 
favorable,  union  taking  place  in  the  great  majority  of  cases  in  from 
three  to  five  weeks.  There  is,  however,  a  certain  amount  of  per- 
manent deformity  in  the  majority  of  cases,  due  to  shortening  and 
over-riding  of  the  fragments.  Delayed  union  or  failure  of  union  may 
result  from  comminution  and  separation  of  the  broken  ends  by  bone 
fragments,  clots,  or  shreds  of  tissue. 

Treatment. — The  treatment,  to  be  successful,  must  first  effect  a 
complete  reduction  of  the  deformity  and  then  maintain  the  fragments 
in  this  position  until  union  has  occurred.  This  is  by  no  means  easy. 
Probably  the  best  result  could  be  obtained  by  keeping  the  patient  in 
the  dorsal  recumbent  posture  with  a  small  pillow  between  the  shoulders, 
but  this  in  the  great  majority  of  instances  would  be  wholly  imprac- 
ticable. As  the  chief  deformity  is  due  to  the  action  of  the  sternomas- 
toid muscle  in  elevating  the  inner  fragment,  and  to  the  dropping 
downward  and  inward  of  the  shoulder  and  outer  fragment,  producing 


830 


FRACTURES 


an  overriding,  reduction  is  accomplished  best  by  carrying  the  elbow 
backward  and  upward;  this  carries  the  outer  fragment  outward  and 
upward,  and  at  the  same  time  renders  tense  the  clavicular  fibres  of 
the  pectoralis  major,  thereby  opposing  the  action  of  the  sternomastoid. 
This  position  is  easily  maintained  by  the  application  of  Moore's 
figure-of-eight  bandage  from  the  elbow  to  the  opposite  shoulder  (Figs. 
384  and  385).  This  dressing,  if  properly  applied  and  frequently 
inspected  to  prevent  slipping  from  the  shoulders  and  loosening,  gives 
by  far  the  best  results  of  any  apparatus  or  method  of  dressing  known 
to  the  writer.  Perhaps  the  dressing  most  frequently  employed  and, 
on  the  whole,  the  most  desirable  when  the  patient  cannot  be  frequently 


Fig.  386. — Sayre's  adhesive  plaster  dress- 
ing for  fractured  clavicle.     Front  view. 


Fig.    387. — Sayre's    adhesive    plaster 
dressing  for    fractured    clavicle.     Rear 


seen  and  examined,  is  the  Sayre  dressing  shown  in  Figs.  38fi  and  387, 
which  consists  of  two  strips  of  adhesive  plaster,  one  encircling  the  arm 
about  its  middle  and  carried  backward  around  the  body,  the  other 
passed  around  the  elbow  and  opposite  shoulder.  The  first  acts  as  a 
fulcrum;  the  second,  by  drawing  the  elbow  forward  and  upward, 
forces  the  shoulder  upward  and  backward.  In  applying  this  it  is  very 
important  to  use  plenty  of  padding  under  the  plaster  encircling  the 
arm,  especially  along  its  upper  edge. 

The  Velpeau  bandage  has   also  been  extensively  employed,   but 
as  it  always  tends  to  increase  the  deformity  it  is  not  to  be  recom- 


FRACTURES  OF  BONES  OF  THE   UPPER  EXTREMITIES     831 

mended.  When  the  conditions  are  such  that  some  measure  of  defor- 
mity cannot  be  avoided,  the  simple  sling  and  body-binder  will  be 
found  useful  (Figs.  59  and  60). 

Union  with  deformity  or  delayed  union  can  be  successfully  treated 
by  an  open  operation,  accurate  reduction,  and  suture  of  the  fragments 
with  chromicized  catgut  or  the  application  of  a  metal  plate. 

In  fractures  of  the  outer  third  the  presence  of  marked  displacement 
means  that  the  coracoclavicular  ligament  has  been  either  ruptured 
or  torn  from  its  attachments.  This  will  be  shown  in  the  arrays  by  the 
increased  distance  between  the  coracoid  and  the  clavicle.  When  this 
occurs  the  ligament  must  be  repaired  either  by  suture  of  its  fibres 
or  by  passing  a  heavy-braided  silk  cord  over  the  clavicle  and  under 
the  coracoid. 

Humerus. — Fractures  of  the  humerus  are  less  frequent  than  fractures 
of  the  clavicle  or  forearm,  and  are  conveniently  divided  into  three 
main  groups:  fractures  of  the  upper  extremity,  shaft,  and  lower 
extremity. 

Fractures  of  the  Upper  Extremity  of  the  Humerus  include  those  of  the 
anatomic  neck,  intracapsular,  above  the  tuberosities,  which  are  very 
rare;  those  of  one  or  both  tuberosities,  associated  with  a  line  of  fracture 
through  the  anatomic  neck,  somewhat  more  frequent;  those  of  the 
greater  or  lesser  tuberosity  alone,  rare,  and  generally  associated  with 
dislocation;  those  of  the  surgical  neck,  which  include  all  of  those 
lying  above  the  attachment  of  the  pectoralis  and  teres  major  and 
below  the  epiphyseal  line,  and  which  constitute  by  far  the  greater 
number  of  fractures  of  the  upper  extremity  of  the  bone;  and  separa- 
tions of  the  upper  epiphysis,  which  may  occur  before  the  twentieth 
year.  Fractures  of  the  anatomic  neck,  with  or  without  involvement 
of  the  tuberosities,  are  generally  due  to  falls  or  blows  on  the  shoulder; 
those  of  the  surgical  neck  may  be  produced  by  direct  violence,  by 
falls  upon  the  elbow,  or  by  cross-strain,  the  arm  being  fixed  by  muscular 
action,  the  injury  generally  taking  place  on  the  outer  side  of  the  bone, 
or  by  forcible  rotation  of  the  bone. 

Diagnosis. — This  in  fractures  of  the  anatomic  neck  may  be  impos- 
sible without  .r-ray  examination,  as  no  deformity  exists,  and  the  only 
sign  may  be  pain  in  the  joint  increased  by  motion  (Stimson).  Fracture 
of  the  anatomic  neck,  however,  may  be  assumed  when  there  are  pain 
and  crepitus  high  up  in  the  joint  without  deformity,  when  the  tuber- 
osities rotate  with  the  shaft,  and  when  fracture  of  the  glenoid,  coracoid, 
or  acromion  can  be  excluded. 

If  tenderness  over  the  tuberosities  exists,  crepitus,  and  an  evident 
thickening  of  the  bone  in  this  region,  fracture  of  the  anatomic  neck 
involving  one  or  both  tuberosities  may  be  assumed;  if  no  crepitus 
can  be  obtained  and  there  is  a  slight  shortening,  the  fracture  is 
probably  impacted. 

In  fracture  of  the  greater  tuberosity  alone  there  are  localized  tender- 
ness and  pain  on  outward  rotation.  It  is  generally  associated  with 
dislocation  of  the  head. 


832  FRACTURES 

In  fracture  through  the  surgical  neck  the  deformity  is  usually 
characteristic;  there  is  angular  deformity  of  the  arm  just  below  the 
point  of  the  shoulder  with  deviation  inward  of  the  axis  of  the  arm, 
caused  by  the  drawing  inward  of  the  lower  fragment  by  the  pectoralis 
major,  and  the  slight  flexion  and  rotation  outward  of  the  upper  frag- 
ment by  the  muscles  attached  to  the  tuberosities.  The  lower  portion 
of  the  arm  is  usually  abducted  and  supported  by  the  opposite  hand 
of  the  patient.  The  shoulder  is  lowered,  but  not  flattened  as  in  dis- 
location, and  the  acromion  is  not  prominent.  Localized  pain  and 
crepitus  are  easily  obtained  by  palpation  at  the  point  of  injury  while 
gently  rotating  the  bone  from  below,  and  this  rotary  motion  is  not 
shared  by  the  tuberosities,  unless  the  fragments  are  impacted. 
Shortening  is  usually  noticeable  from  drawing  upward  of  the  lower 
fragment,  the  point  of  which  can  often  be  felt  under  the  skin  in  the 
axilla  or,  rarely,  under  the  coracoid.  Dislocation  can  be  positively 
excluded  by  feeling  the  head  of  the  bone  in  place,  by  a  fulness  instead 
of  a  flattening  just  below  the  acromion,  and  by  placing  the  hand  on 
the  opposite  shoulder  and  noting  that  the  elbow  can  easily  be  made  to 
touch  the  wall  of  the  thorax. 

Complications. — Injury  to  the  large  vessels  and  nerve  trunks  of 
the  axilla  by  the  sharp  lower  fragment  of  bone  has  been  reported, 
giving  rise  to  more  or  less  extensive  circulatory,  motor,  and  sensory 
disturbances  of  the  arm,  the  latter  due  to  direct  injury  of  the  nerves, 
to  a  subsequent  neuritis,  or  involvement  of  the  nerve  in  the  callus. 
The  association  of  fracture  in  this  region  with  dislocation  or  with 
injury  to  other  neighboring  bones  may  render  the  diagnosis  obscure 
and  present  many  difficulties  in  treatment. 

Prognosis. — In  the  absence  of  complications  fracture  at  the  upper 
extremity  of  the  humerus  is  an  injury  in  which  a  good  functional 
result  may  be  expected,  bony  union  taking  place  in  the  majority  of 
instances  in  which  satisfactory  reduction  has  been  effected.  Exu- 
berant callus  and  bony  outgrowths  may  occur  occasionally,  especially  in 
fractures  involving  the  tuberosities,  and  may  give  rise  to  permanent 
limitation  of  motion. 

Treatment. — In  all  doubtful  cases  general  anesthesia  should  be 
induced  and  a  careful  examination  made.  In  fracture  of  the  anatomic 
neck  without  displacement  all  that  is  necessary  is  to  immobilize  the 
arm  and  protect  the  parts  from  further  injury.  This  is  accomplished 
best  by  the  use  of  the  sling  and  body-binder,  as  shown  in  Figs.  59 
and  60.  If  there  is  displacement,  as  shown  by  the  .r-rays,  the  arm 
should  be  immobilized  in  that  position  which  best  approximates  the 
fracture  surfaces.     This  will  usually  be  in  abduction. 

Fractures  through  the  tuberosities,  if  impacted,  should  be  left 
undisturbed  if  motion  of  the  joint  is  not  hindered,  and  may  be  treated 
by  the  same  simple  method,  or  by  the  internal  angular  splint  with 
or  without  a  shoulder-cap.  With  separation  of  the  fragments  immo- 
bilization in  abduction  may  maintain  apposition.     If  this  is  not  sue- 


FRACTURES  OF  BONES  OF  THE   UPPER  EXTREMITIES     833 

cessful  open  reduction  with  suture  or  nailing  is  indicated.  Fractures 
through  the  surgical  neck,  high  up,  may  present  little  or  no  displace- 
ment, and  be  treated  similarly,  but  in  the  great  majority  of  instances 
fractures  of  the  surgical  neck  require  for  their  treatment  some  appara- 
tus which  combines  extension  with  a  firm  grasp  of  the  fragments, 
together  with  fixation  of  the  shoulder-  and  elbow-joints.  In  the 
writer's  experience  these  conditions  are  fulfilled  best  by  the  use  of 
a  plaster-of-Paris  spica  extending  from  the  shoulder  to  the  wrist,  the 
elbow  being  flexed  at  a  right  angle  (Fig.  388).  The  method  of  applica- 
tion is  as  follows:    Two  strips  of  adhesive  plaster  are  placed  longitudi- 


Fig.  388. — Plaster  spica,  arm  and  shoulder. 


nally  on  either  side  of  the  lower  half  of  the  upper  arm,  the  ends  hang- 
ing free  below  the  elbow.  The  upper  part  of  the  thorax,  shoulder, 
and  arm  are  next  enveloped  in  two  or  more  layers  of  sheet  wadding; 
firm  extension  is  then  made  by  an  assistant  on  the  traction  straps  to 
overcome  shortening,  and  the  plaster  rollers  are  applied  in  the  usual 
manner.  Extension  is  maintained  until  the  plaster  is  hardened. 
This  dressing  is  applicable  to  all  fractures  of  the  humerus  in  which 
a  tendency  to  recurrence  of  the  deformity  is  present. 

In  epiphyseal  separation  of  the  upper  extremity  of  the  humerus 
the  deformity  is  characteristic,  owing  to  the  projection  of  the  anterior 
sharp  margin  of  the  lower  fragment  an  inch  below  the  acromion, 
53 


s:;4 


FRACTURES 


the  posterior  margin  of  the  shaft  being  lodged  in  the  concavity  of  the 
upper  fragment  (Figs.  389  and  390).  Reduction  of  the  deformity  is 
accomplished  best  by  raising  the  arm  anteriorly  above  the  head 
(Moore),  after  which  the  fragments  are  kept  in  place  by  the  plaster- 
of-Paris  spica,  the  arm  being  elevated  and  abducted  to  forty-five 
degrees. 

It  occasionally  happens  in  fractures  about  the  shoulder-joint, 
particularly  in  epiphyseal  separations,  and  in  fractures  complicated 
by  dislocation  of  the  head,  that  open  operation  is  to  be  recommended 
when  the  ordinary  methods  of  manipulation  fail  to  effect  reduction. 
The  region  of  the  joint  is  best  exposed  by  a  curved  incision  extending 
from  the  tip  of  the  coracoid  outward  and  downward  for  four  or  five 
inches  and  deepened  to  the  deltoid  muscle.    This  flap  is  then  dissected 


Fig.  389. — Upper  epiphysis  of  the 
humerus  at  ten  years;  separated  by 
maceration.    Outer  side.     (Moore.) 


Fig.  390. — Separation  of  the  upper  epiphysis 
of  the  humerus;  displacement  forward  of  the 
lower  fragment.     (Moore.) 


iij)  and  the  deltoid  separated  from  the  pectoralis  major,  avoiding  the 
cephalic  vein.  If  necessary  to  obtain  additional  room  the  anterior 
fibres  of  the  deltoid  are  cut  transversely  a  half-inch  from  their  clavic- 
ular attachment  and  the  muscle  flap  turned  outward.  If  the  deltoid 
is  split  the  nerve  supply  to  the  anterior  fibres  is  destroyed  and  this 
portion  will  atrophy. 

Fractures  of  the  Shaft  of  the  Humerus  are  quite  common,  and  are 
due  to  direct  and  indirect  violence  and  to  muscular  action,  the  latter 
cause  being  more  frequently  observed  in  this  fracture  than  in  fracture 
of  other  long  bones. 

The  line  of  fracture  may  a>sume  almost  any  direction,  but  is  more 
commonly  transverse.  Displacement  is  often  considerable,  and 
extensive  injury  to  the  soft  parts  is  frequent,  with  occasional  lesion  of 


FRACTURES  OF  BOXES  OF  THE   UPPER  EXTREMITIES     835 

the  musculospiral  nerve  and  larger  bloodvessels.  Delayed  union  and 
failure  of  the  hone  to  unite  are  more  frequently  ohserved  in  fractures 
near  the  middle  of  the  humerus  than  in  any  other  hone  of  the  body, 
due  to  separation  of  the  fragments  by  strips  of  muscle  or  fascia,  or 
to  imperfect  immobilization  of  the  parts.  This  fact  and  the  possibility 
of  paralysis  from  musculospiral  nerve  injury  should  always  be  remem- 
bered in  making  a  prognosis. 

Diagnosis. — The  diagnosis  is  easily  made,  as  deformity,  abnormal 
mobility,  and  crepitus  are  readily  appreciated. 

Treatment. — Reduction  should  be  effected  and  the  fragments  held  in 
place  by  a  plaster-of-Paris  spica  from  the  shoulder  to  the  wrist,  the  elbow 
being  flexed  across  the  body  (Fig.  388).  The  use  of  an  external  plaster- 
of-Paris  splint  moulded  over  the  shoulder  and  extending  to  the  hand  is 
lighter  and  often  quite  as  serviceable.  Internal  angular  splints  alone 
are  to  be  condemned,  as  they  always  allow  a  certain  amount  of  motion 
between  the  fragments.  If  reduction  cannot  be  maintained  in  this 
way,  if  muscular  interposition  is  suspected  because  of  lack  of  crepitus 
at  the  time  of  reduction,  or  if  there  is  any  evidence  of  musculospiral 
involvement,  an  open  reduction  is  indicated  and  usually  the  application 
of  a  metal  plate.  The  best  route  for  the  middle  third  is  between  the 
outer  and  middle  heads  of  the  triceps. 

The  treatment  of  compound  fractures  in  this  region  differs  in  no 
respect  from  those  of  other  long  bones. 

Fractures  of  the  Lower  Extremity  of  the  Humerus. — Fractures  of  the 
lower  extremity  of  the  humerus  are  divided  into  five  classes:  transverse 
fractures  above  the  condyles;  T-fractures  into  the  joint;  fractures  of 
the  external  condyle;  fractures  of  the  internal  condyle;  and  epiphyseal 
separations.  In  all  of  these  varieties  of  fracture  the  cause  is  direct 
or  indirect  violence,  generally  falls  or  blows  upon  the  hand  or  elbow. 
They  are  more  frequent  in  children  than  in  adults. 

Diagnosis. — In  fracture  above  the  condyles  the  direction  is  generally 
transverse  from  side  to  side,  but  oblique  from  above  and  behind 
downward  and  forward.  The  lower  fragment  is  drawn  backward  and 
upward  by  the  action  of  the  triceps,  and  the  upper  fragment  projects 
downward,  making  a  prominence  in  front,  just  above  the  joint-line. 
This  backward  displacement  of  the  lower  fragment  creates  a  deformity 
somewhat  resembling  that  produced  by  a  backward  dislocation  at  the 
elbow.  The  points  in  differential  diagnosis  are:  The  normal  relations 
of  the  epicondyles  and  olecranon,  ease  of  reduction,  tendency  to  a 
return  of  the  deformity,  the  projection  in  front  of  the  joint  above  the 
joint-line  being  rough  and  irregular,  and  the  presence  of  crepitus.  An 
anterior  or  lateral  displacement  of  the  lower  fragment  may  occur, 
giving  rise  to  atypical  deformities  (Fig.  391). 

In  the  T-fracture,  in  addition  to  the  transverse  line  of  fracture 
above  the  condyles,  there  is  a  line  of  separation  extending  from  this 
to  the  articular  surface  ( Fig.  392).  As  this  fracture  involves  the  joint, 
there  is,  in  addition  to  the  signs  of  the  supracondyloid  fracture,  an 


s::ii 


FRACTURES 


Fig.  391. — Supracondyloid  fracture.  Fig.  392. — T-fracture  of  humerus.    (Helferich.) 

(Stimson.) 


Fig.  393. — Four  years.1 


Fig.  394. — Six  years. 


1  Figs.  393,  394,  395,   396,    397,  398. — Epiphyseal  development  of  the  lower  end^of 
the  humerus. 


FRACTURES  OF  BONES  OF  THE   UPPER  EXTREMITIES     837 


Fig.  395. — Nine  years. 


Fig.  396. — Eleven  years. 


Fig.  397. — Fourteen  years. 


Fig.  398. — Seventeen  years. 


838  FRACTURES 

increase  in  distance  between  the  two  epicondyles,  separate  mobility 
of  each  condyle,  and  an  effusion  into  the  synovial  cavity. 

In  fractures  of  the  external  condyle  the  line  of  fracture  may  be 
wholly  external  to  the  joint  (fracture  of  the  epicondyle),  or  it  may 
pass  obliquely  into  the  joint  from  a  point  just  above  the  epicondyle,  or 
from  a  point  just  below  the  epicondyle  (capitellar  fracture).  The 
same  is  true  of  fractures  of  the  internal  condyle.  In  the  former  the 
diagnostic  points  are  pain  on  motion,  tenderness  over  the  outer  side 
of  the  joint,  separate  mobility  of  the  external  condyle,  crepitus,  and  a 
tendency  to  abduction  of  the  forearm.  In  the  latter  the  same  signs 
are  present  on  the  inner  aspect  of  the  elbow  and  a  tendency  toward 
adduction  of  the  forearm. 

If  the  displacement  is  slight,  the  relation  of  the  epicondyles  and 
olecranon  may  not  be  altered;  generally,  however,  the  fractured 
epicondyle  is  somewhat  higher  than  its  fellow,  and  in  the  case  of  the 
internal  condyle  there  is  often  a  displacement  backward  due  to  the 
upward  traction  of  the  ulna  by  the  triceps. 

Epiphyseal  separations  are  rare,  occur  at  an  early  age,  and  generally 
consist  in  a  separation  of  the  articular  surface  below  the  epicondyles. 
(Fractures  of  the  articular  surface  have  also  been  reported  in  later  life.) 
As  these  fractures  lie  within  the  capsule  of  the  joint  the  tendency  to 
marked  deformity  is  slight.  The  signs  are  slight  backward  displace- 
ment, which  is  easily  corrected,  and  is  as  easily  reproduced;  muffled 
crepitus,  and  finding  the  epicondyles  attached  to  the  shaft  of  the  bone. 

A  study  of  the  development  of  the  lower  extremity  of  the  bone, 
as  described  by  Henle  and  illustrated  in  Figs.  393  to  398,  will  show 
that  in  very  early  life  a  separation  may  occur  which  will  include 
the  epicondyles  in  the  lower  fragment.  At  a  later  period  the  line  of 
separation  must  be  below  the  internal  epicondyle,  but  may  be  above 
the  external  epicondyle.  It  is  not  improbable  that  in  many  of  the 
injuries  described  as  fractures  of  the  external  condyle  occurring  before 
the  seventeenth  year  the  lesion  is  a  separation  through  the  cartilage 
connecting  the  shaft  with  the  ossified  epicondyle  and  capitellum. 

Complications. — Fractures  at  the  lower  end  of  the  humerus  are 
rarely  compound.  They  are  occasionally  comminuted,  and  not 
infrequently  are  accompanied  by  injury  to  the  ulnar  or  musculospiral 
nerve,  the  former  more  commonly  in  fracture  of  the  internal  condyle, 
the  latter  in  those  of  the  external  condyle. 

Treatment. — In  all  of  these  fractures  the  diagnosis  should  be  verified 
by  an  examination  under  general  anesthesia  and  with  the  .r-rays. 
Reduction  is  generally  easy,  but  difficult  to  maintain.  In  transverse 
fractures,  supracondyloid  and  epiphyseal,  reduction  is  accomplished 
by  traction  in  a  hyperextended  position,  followed  by  acute  flexion. 
In  T-fractures  and  fractures  of  the  internal  or  external  condyle 
Cotton  advises  dressing  the  arm  in  an  acutely  flexed  position. 
This  position,  with  pressure  on  the  epicondyles,  serves  to  reduce 
the  fracture,  and    should    be    maintained  by  a  strip  of  zinc   oxide 


FRACTURES  OF  BONES  OF  THE   UPPER  EXTREMITIES     839 

plaster  passed  around  the  wrist  and  upper  part  of  the  arm  (Fig. 
399).  The  flexed  arm  is  then  placed  snugly  against  the  lateral 
chest  wall  on  a  gauze  pad,  and  held  in  place  by  a  broad  bandage 
of  folded  muslin  applied  as  shown  in  Fig.  400.  If  the  forearm 
is  placed  across  the  anterior  chest  wall  the  lower  fragment  is  rotated 
inward  on  the  shaft  and  tends  toward  a  rotatory  displacement.  The 
use  of  a  plaster-of-Paris  bandage  extending  from  the  shoulder  to  the 
wrist  has  many  advantages,  especially  in  young  children.  In  any  case 
it  is  desirable  after  the  application  of  the  dressing  to  examine  the 
parts  with  the  x-rays. 


Fig.  399. — Arm  dressed  in  the  acutely 
flexed  position.     First  stage. 


Fig.  400. — Arm  dressed  in  the  acutely 
flexed  position.     Second  stage. 


When  reduction  is  perfect,  union  is  rapid,  and  if  the  joint  is  not 
involved,  a  good  functional  result  may  be  expected.  In  all  fractures 
extending  into  the  joint  passive  motion  should  be  practised  early  and 
persistently  but  very  gently.  It  may  be  commenced  at  the  end  of 
two  weeks,  should  be  employed  every  other  day  at  first,  and  later 
every  day  if  there  is  much  limitation  of  motion.  The  combination  of 
motion  and  massage  will  be  found  useful  in  most  cases.  Limitation 
of  motion  at  the  elbow  after  fracture  is  generally  due  to  mechanical 
obstruction  from  misplaced  fragments,  to  a  deposit  of  callus  in  the 


840  FRACTURES 

olecranon  or  coronoid  fossa,  to  fibrous  thickening  of  the  fat  pads  in 
these  fossae,  or  to  inflammatory  adhesions  in  the  joint.  Considering 
the  frequency  of  these  complications,  the  prognosis  in  every  case 
should  be  guarded. 

Operative  treatment  of  fractures  of  the  lower  end  of  the  humerus 
may  be  necessary,  to  effect  reduction  of  the  fragments  when,  for 
any  reason,  such  reduction  cannot  be  brought  about  by  the  ordinary 
non-operative  methods;  to  remove  non-viable  fragments  of  bone; 
to  relieve  nerve  pressure  or  to  increase  the  range  of  motion  after 
vicious  union  has  occurred.  The  best  route  is  the  anteroexternal. 
The  internal  margin  of  the  brachioradial  muscle  (supinator  longus) 
is  identified  and  this  separated  from  the  brachialis  anticus.  After 
the  musculospiral  nerve  is  identified  the  fibers  of  the  brachialis  anticus 
are  split  a  half-inch  internal  to  the  nerve  and  the  bone  thus  exposed. 
For  high  supracondylar  fractures  the  posterior  route,  splitting  the 
triceps,  may  be  preferable,  especially  if  a  plate  has  to  be  applied. 
When  the  seat  of  fracture  is  exposed  the  bones  should  be  accurately 
readjusted,  and  held  in  place  by  sutures  of  chromic  gut,  screws,  nails, 
bolts,  or  metal  plates,  or  simply  by  the  position  of  the  extremity. 
The  wound  should  then  be  closed,  without  drainage,  and  a  plaster- 
of-Paris  cast  applied.  Motion  should  be  commenced  as  early  as  the 
third  week,  and  massage  as  soon  as  the  fragments  have  sufficiently 
united  to  prevent  easy  displacement. 

Fractures  of  the  Forearm. — Fractures  of  the  forearm  are  commonly 
divided  into  those  occurring  near  the  elbow,  those  occurring  in  the 
shaft  of  one  or  both  bones,  and  those  occurring  near  the  wrist-joint. 

Fractures  in  the  neighborhood  of  the  elbow-joint  are  those  of  the 
olecranon,  coronoid  process,  and  of  the  head  and  neck  of  the  radius. 

Fractures  of  the  Olecranon. — Fractures  of  the  olecranon  are  of 
comparatively  frequent  occurrence.  They  result  commonly  from  falls 
or  blows  on  the  elbow,  from  muscular  strain,  or  from  both  causes 
combined.  If  the  fracture  occurs  near  the  shaft  of  the  bone,  there  may 
be  only  a  slight  separation,  the  fragment  being  held  in  place  by  the 
muscular  and  aponeurotic  attachments.  Generally,  however,  the 
detached  fragment  is  drawn  upward  by  the  triceps,  and  a  distinct 
sulcus  is  present  which  can  easily  be  appreciated  by  the  examining 
finger. 

Diagnosis. — The  diagnosis  is  established  by  the  presence  of  localized 
pain  and  tenderness,  abnormal  mobility  of  the  separated  fragment, 
swelling  of  the  joint,  and  inability  to  extend  the  forearm  fully.  Crep- 
itus is  generally  absent,  owing  to  separation  of  the  fragments. 

Treatment, — The  treatment  consists  in  fixation  of  the  arm  in  a 
partially  extended  position.  As  complete  extension  is  more  or  less 
uncomfortable  to  most  patients,  a  slight  flexion  to  15  or  20  degrees 
may  be  allowed.  All  attempts  by  bandages  or  adhesive  straps  to 
overcome  the  powerful  action  of  the  triceps  muscle  in  drawing  the 
loose  fragment  upward  are  useless,  and  only  serve  to  constrict  the  soft 


FRACTURES  OF  BONES  OF  THE  UPPER  EXTREMITIES     841 

parts  and  favor  edema.  If  any  appreciable  degree  of  separation  is 
present,  the  union  is  always  fibrous,  and  the  separation  of  the  fragments 
may  be  inereased  by  the  later  use  of  the  arm.  For  this  reason  it  is 
wiser  to  expose  the  site  of  injury  by  a  U-shaped  incision,  remove  the 
blood  clots  from  the  joint  and  hold  the  fragments  in  apposition  by 
an  encircling  suture  of  heavy  silk  or  chromic  gut.  This  should  pierce 
the  triceps  insertion  transversely  above  and  pass  through  a  hole 
drilled  in  the  ulnar  shaft  below. 

Fractures  of  the  Coronoid  Process. — Fractures  of  the  coronoid  process 
are  rare  and  almost  always  associated  with  a  backward  dislocation  of 
both  bones. 

Symptoms. — The  symptoms  characteristic  of  this  condition  are: 
A  backward  dislocation  at  the  elbow,  which  is  reduced  with  more  than 
ordinary  ease,  but  -in  which  a  tendency  to  redislocation  is  marked, 
and  the  presence  of  a  small  fragment  of  bone  in  front  of  the  joint, 
drawn  upward  by  the  action  of  the  brachialis  anticus  muscle.  Crepitus 
is  rarely  obtained  except  in  the  position  of  extreme  flexion. 

Treatment. — The  treatment  of  this  fracture  consists  in  reduction  of 
the  dislocation  and  immobilizing  the  arm  in  a  flexed  position,  the 
degree  of  flexion  necessary  being  determined  by  the  point  at  which 
crepitus  can  be  obtained,  generally  somewhat  more  than  a  right  angle. 
If  this  position  fails  to  obtain  sufficient  approximation  as  shown  by 
the  .r-rays,  the  coronoid  may  be  exposed  through  an  antero-external 
incision  and  held  in  place  by  a  long  screw  or  suture. 

Fractures  of  the  Upper  Extremity  of  the  Radius. — Fractures  of  the 
upper  extremity  of  the  radius  may  be  limited  to  the  head,  stellate 
fissures  or  complete  separation  of  a  fragment;  or  they  may  involve 
the  neck  cf  the  bone,  in  which  case  they  are  generally  transverse 
and  usually  impacted.  »They  may  occur  as  a  result  of  direct  violence, 
usually  a  fall  or  blow  on  the  outer  aspect  of  the  elbow  or  indirectly 
from  a  fall  on  the  extended  hand,  the  elbow  being  in  full  extension. 
They  are  occasionally  associated  with  a  dislocation. 

Diagnosis. — The  diagnosis  is  often  uncertain  unless  confirmed  by  a 
radiograph  or  incision.  The  symptoms  suggesting  the  lesion  are  pain, 
localized  tenderness,  and  occasionally  crepitus  on  pronation  and 
supination,  without  marked  deformity.  Marked  limitation  of  flexion 
pronation,  and  supination  may  be  occasioned  by  the  presence  of  a  loose 
fragment  of  the  bone  in  the  joint  cavity. 

Treatment. — If  the  fragment  lies  in  front  of  the  lower  humeral  surface 
where  it  will  interfere  with  flexion,  the  treatment  should  be  open 
incision,  thorough  inspection,  and  removal  of  any  fragment  of  bone. 
Excision  of  the  head  of  the  bone  may  be  required  if  there  is  much 
comminution  and  displacement  of  the  fragments.  The  incision 
which  best  exposes  this  portion  of  the  joint  is  the  posterolateral  curved 
one  between  the  anconeus  and  extensor  carpi  ulnaris. 

If  no  deformity  exists  and  little  or  no  limitation  of  the  normal 
movements,  fixation  of  the  elbow  at  a  right  angle  is  all  that  is  recpiired 


842  FRACTURES 

in  the  way  of  treatment.     The  amount  of  displacement  rather  than 

the  extent  of  the  fracture  should  he  the  guide  for  operation. 

As  in  all  fractures  involving  the  elbow-joint,  early  massage  and 
passive  motion  are  essential. 

Fractures  of  the  Shaft  of  One  or  Both  Bones. — Fractures  of  the  shaft 
of  one  or  both  bones  of  the  forearm  are  of  frequent  occurrence,  and 
may  be  produced  by  direct  or  indirect  violence.  Fractures  of  the  ulna 
alone  are  slightly  more  frequent  than  those  of  the  radius  alone,  and  are 
almost  always  produced  by  direct  violence,  as  a  blow  upon  the  outer 
aspect  of  the  arm  as  when  that  member  is  raised  to  guard  the  face  in 
boxing.  Fractures  of  the  shaft  of  the  radius  are  often  the  result  of 
direct  violence,  but  are  more  generally  produced  by  indirect  violence, 
as  a  fall  on  the  hand.  Muscular  action  alone  is  rarely  responsible 
for  these  fractures.  When  the  ulna  alone  is  broken  the  displacement 
is  often  slight,  unless  the  injury  is  complicated  by  a  dislocation  of 
the  head  of  the  radius,  in  which  event  the  displacement  may  be  con- 
siderable, and  its  direction  is  more  influenced  by  the  fracturing  force 
than  by  the  action  of  muscles.  In  fractures  of  the  radius  above  the 
insertion  of  the  pronator  radii  teres  muscle  the  upper  fragment  is 
drawn  upward  and  outward  by  the  biceps  and  strongly  supinated  by 
the  same  muscle  and  the  supinator  brevis;  in  fractures  below  that 
point  the  tendency  of  the  fragments  is  toward  the  ulna,  the  upper 
one  being  often  drawn  upward  by  biceps  influence.  In  fractures  of 
both  bones  almost  any  variety  of  displacement  may  be  present,  the 
fracturing  force  being,  as  a  rule,  a  more  potent  agent  in  its  production 
than  action  of  the  muscles. 

Diagnosis. — Fractures  of  the  forearm  occurring  in  the  shafts  of 
the  bones  are  more  readily  recognized  than  those  at  either  extren  ity. 
If  both  bones  are  fractured,  there  is,  as  a  rule,  considerable  angular 
deformity  of  the  forearm,  either  present  or  easily  produced;  localized 
tenderness,  false  motion,  and  crepitus  are  easily  elicited,  and  shortening 
is  generally  present.  In  fractures  of  the  radius  alone  some  deformity 
is  often  present,  due  to  the  upward  traction  of  the  biceps  on  the  upper 
fragment.  On  pronation  and  supination  the  rotation  is  not  communi- 
cated to  the  head  of  the  bone,  and  there  is  always  to  be  found  a  local 
point  of  tenderness,  generally  with  crepitus.  In  fractures  of  the  shaft 
of  the  ulna  localized  tenderness  may  be  the  only  symptom.  The  i"S2 
of  the  x-rays  is  of  great  value  in  these  cases,  not  only  for  diagnosis, 
but  also  in  treatment,  for  accurate  reduction  in  these  cases  is  essential 
to  insure  a  satisfactory  functional  result. 

Com  plications. — In  perhaps  no  fractures  in  the  body  are  circulatory 
disturbances  as  frequent  as  in  fractures  of  the  forearm.  They  are 
generally  due  to  faulty  application  of  the  splints  and  dressings,  and 
result  in  local  sloughs,  ischemic  paralysis  of  the  muscles,  and  occasion- 
ally gangrene  of  the  extremity.  Delayed  union  and  failure  of  union 
are  to  be  feared  if  the  reduction  has  been  imperfect,  and  a  temporary 
or  permanent  impairment  of  the  function  of  pronation  and  supination 


FRACTURES  OF  BONES  OF  THE   UPPER  EXTREMITIES     843 

frequently  follows,  not  only  from  faulty  reduction,  but  also  from 
exuberant  callus  when  the  muscles,  periosteum,  and  interosseous 
membrane  have  been  extensively  lacerated.  In  fractures  of  the  radius 
alone,  if  there  is  any  shortening,  either  from  over-riding  or  from  angula- 
tion, there  will  be  a  derangement  at  the  inferior  radio-ulnar  joint  with 
persistent  pain  and  interference  with  pronation  and  supination,  from 
a  relative  lowering  of  the  ulnar  head. 

Treatment. — When  possible,  fractures  of  the  forearm  should  be 
examined,  reduced,  and  the  dressings  applied  under  the  guidance 
of  the  x-rays,  so  great  is  the  importance  of  accurate  coaptation  of 
the  fragments.  When  this  is  not  practicable,  reliance  must  be 
placed  upon  the  correction  of  the  apparent  deformity  and  the 
restoration  of  function.  When  reduction  has  been  effected,  which 
often  requires  considerable  force,  the  arm  should  be  flexed  at  the 
elbow  and  the  hand  placed  in  a  position  midway  between  pronation 
and  supination,  with  the  thumb  pointing  upward.  Retention  in 
this  position  should  be  accomplished  by  the  use  of  moulded  plaster 
splints,  or  a  circular  plaster  extending  from  the  middle  of  the  arm 
to  the  base  of  the  fingers.  If  the  circular  plaster  is  used  it  should 
be  completely  cut  through  on  both  sides  while  still  moist  and  then 
reinforced  with  a  few  turns  of  a  gauze  bandage.  If  there  is  the  slightest 
sign  of  circulatory  interference  the  latter  must  be  removed  and  the  two 
halves  of  the  plaster  bandage  separated  slightly.  The  use  of  a  pad, 
graduated  compress  or  rubber  tubing  between  the  bones  to  prevent 
lateral  approximation,  is  of  no  value,  and  serves  only  to  compress  the 
tissues  and  favor  interference  with  circulation.  Inspection  by  the 
fiuoroscope  or  radiograph  should  always  be  made  after  the  application 
of  the  final  dressing. 

In  fractures  of  the  radius  above  the  insertion  of  the  pronator  radii 
teres,  if  there  is  a  marked  tendency  to  supination  of  the  upper  fragment 
which  is  not  corrected  by  flexing  the  elbow,  it  is  desirable  to  dress  the 
arm  in  a  position  of  greater  supination  than  normal.  Extreme  supina- 
tion is  to  be  avoided,  as  it  causes  much  discomfort  to  the  patient. 
In  the  event  of  failure  to  reduce  the  deformity  or  to  bring  about 
accurate  coaptation  of  the  fragments,  or  if  interposition  of  soft  parts 
is  suspected  because  of  the  lack  of  crepitus,  open  operation  and  accurate 
replacement  are  to  be  advised.  Simple  open  reduction  will  usually 
be  all  that  is  necessary,  but  if  the  deformity  tends  to  recur,  suture 
or  plating  is  indicated. 

Fractures  in  the  Vicinity  of  the  Wrist-joint. — These  are  fractures 
at  the  lower  end  of  the  radius  (Colles'  fracture),  fractures  of  both 
bones  just  above  the  wrist,  and  fractures  of  the  styloid  process  of  the 
radius  or  ulna. 

Colles'  Fracture. — -Colles'  fracture,  named  after  the  Dublin  surgeon 
who  first  accurately  described  the  injury,  consists  in  a  fracture  through 
the  radius  just  above  its  inferior  articular  surface.  The  line  of  fracture 
usually  occurs  at  the  point  where  the  shaft  begins  to  widen  into  its 


844  FRACTURES 

inferior  extremity,  as  this  is  the  weakest  part  of  the  bone,  pwing  to 
the  fact  that  the  hard,  compact,  outer  covering  is  largely  replaced  by 
soft,  friable,  cancellous  tissue  before  the  bone  expands  into  the  bulky 
inferior  extremity. 

In  the  majority  of  instances  this  fracture  is  caused  by  a  fall  on 
the  outstretched  hand,  producing  forcible  overextension  at  the  wrist. 
It  is  also  often  due  to  a  "back  fire"  of  the  engine  while  the  patient  is 
cranking  an  automobile.  This  results,  first,  in  a  fracture  at  the  weakest 
point,  the  general  direction  of  which  is  usually  transverse,  the  loose 
fragment  being  driven  upward  with  the  carpus,  making  with  the 
upper  fragment  an  angle  the  apex  of  which  is  directed  toward  the 
flexor  surface  of  the  arm.  The  most  frequent  displacements  of  the 
lower  fragments  are  a  radial  or  a  dorsal  shifting,  a  dorsal  tilting  or 
angulation,  and  an  upward  displacement  or  impaction.  These  may 
occur  alone  or  in  combination.  The  ulna  maintains  its  relation  to  the 
upper  fragment,  and  the  lower  fragment,  together  with  the  carpus, 
loses  its  normal  relation  to  the  ulnar  head.  With  this  is  frequently 
associated  rupture  of  the  internal  lateral  ligament,  or  a  fracture  of  the 
ulnar  styloid.  The  resulting  derangement  of  the  inferior  radio-ulnar 
joint  is  often  overlooked  and  if  uncorrected  may  give  rise  to  permanent 
disability. 

Occasionally  fracture  at  the  lower  end  of  the  radius  is  produced 
by  a  fall  or  blow  on  the  back  of  the  hand,  causing  exaggerated  flexion. 
This  fracture,  which  has  been  carefully  studied  by  J.  B.  Roberts  of 
Philadelphia,  presents  a  deformity  which  may  be  described  as  the 
opposite  of  that  found  in  typical  Colles'  fracture,  the  lower  fragment 
being  driven  downward  and  upward,  causing  with  the  upper  an  angle 
the  apex  of  which  points  backward.  Since  the  general  adoption  by 
surgeons  of  a>ray  examinations  in  fractures,  those  occurring  at  the 
lower  extremity  of  the  radius  have  been  found  to  present  great  variation 
in  the  line  or  lines  of  fractures  and  in  the  position  of  the  fragments. 
The  studies  of  Codman,  of  Boston,  and  of  Beck,  of  New  York,  have 
demonstrated  that  the  typical  Colles'  fracture,  as  described  above, 
occurs  only  in  about  one-half  of  the  cases,  the  other  recognized  forms 
being  an  oblique  fracture  through  the  base  of  the  styloid  process,  an 
oblique  fracture  of  the  inner  angle  of  the  radius,  epiphyseal  separations, 
transverse  and  stellate  fractures  without  displacement,  and  comminuted 
fractures.     Fracture  of  the  ulnar  styloid  is  frequently  present. 

Fracture  of  both  bones  above  the  wrist  is  uncommon.  The  fibres 
of  the  pronator  quadratus  are  very  apt  to  become  interposed  between 
the  radial  fragments  and  to  interfere  with  accurate  reduction. 

Diagnosis. — In  a  typical  Colles'  fracture  with  displacement,  the 
deformity  is  strikingly  characteristic  (Figs.  401  and  402).  There  is  radial 
shortening  and  radial  shifting,  giving  the  hand  an  inclination  toward 
that  side;  the  lower  fragment  and  carpus  project  backward,  while 
the  upper  fragment  is  pushed  forward,  giving  an  appearance  which 
has  been  described  as  "the  silver-fork  deformity;"  the  lower  extremity 


FRACTURES  OF  BONES  OF  THE   UPPER  EXTREMITIES     845 

of  the  ulna  is  displaced  inward  and  forward,  which  widens  the  wrist 
at  that  point.  On  palpation,  the  tip  of  the  radial  styloid  will  be  found 
on  a  level  with  that  of  the  ulna  or  a  little  above  it,  depending  on  the 
amount  of  impaction  (normally  it  lies  a  quarter  of  an  inch  below); 


Fig.  401. — Deformity  in  extreme  type  of  Colles'  fracture. 

the  angular  deformity  is  easily  appreciated;  there  is  tenderness  over 
the  line  of  fracture  and  in  the  region  of  the  ulnar  styloid.  If  the 
fracture  is  not  impacted,  abnormal  mobility  and  crepitus  may  be 
obtained.  The  ability  to  extend  the  hand  is  retained,  while  flexion 
is  limited.     The  arm  is  usually  pronated;  supination  causes  pain. 


Fig.  402. — Deformity  in  extreme  type  of  Colles'  fracture. 


In  Roberts'  fracture  by  hyperflexion,  the  apex  of  the  angular  deformity 
points  backward,  and  extension  of  the  fingers  and  hand  is  limited  and 
painful.  In  transverse  fractures  without  displacement  of  the  fragments 
no  deformity  may  be  present  and  local  tenderness  and  impaired  motion 


846 


FRACTURES 


may  he  the  only  symptoms.  Fractures  of  both  bones  or  of  either 
styloid  are  easily  recognized  by  localized  pain,  abnormal  mobility, 
and  crepitus. 

Complications. — Compound  fractures  in  this  region  are  exceedingly 
rare;  when  present,  they  are  generally  accompanied  by  extensive 
laceration  of  the  soft  parts  with  opening  into  the  joint  or  synovial 
tendon  sheaths,  resulting,  if  infected,  in  permanent  stiffness  and  loss 
of  function.  Extensive  comminution  or  destruction  of  the  cancellous 
bone  tissue  by  impaction  of  the  fragments  may  prevent  complete 
reduction  and  result  in  permanent  deformity.     Ischemic  wasting  of 

the  muscle  from  pressure  of 
splints  or  bandages  is  common 
after  this  fracture  and  delays 
restoration  of  function.  Chronic 
rheumatic  arthritis  frequently 
follows  this  injury  in  those 
predisposed  to  this  affection. 

Prognosis.  —  While  perfect 
restoration  of  function  is  to 
be  expected  when  reduction 
has  been  complete,  it  should 
be  remembered  that  this  is 
often  delayed,  and  stiffness  of 
the  carpal  and  phalangeal 
joints  frequently  remains  for 
a  long  period,  and  requires 
persistent  efforts  on  the  part 
of  the  patient  for  its  removal. 
A  certain  measure  of  deformity 
also  results  in  the  majority  of 
instances,  due  to  incomplete 
reduction  of  the  angular  defor- 
mity, to  loss  of  substance  from 
impaction,  or  to  failure  to  re- 
store completely  the  displaced 
ulna.  Fortunately,  however, 
the  persistence  of  deformity 
does  not  necessarily  entail  a  loss  of  function,  for  a  satisfactory  res- 
toration of  function  generally  follows,  though  perhaps  tardily,  even 
in  cases  of  permanent  and  marked  deformity.  In  uncomplicated 
cases  bony  union  may  be  expected  in  four  weeks.  In  aged  and 
rheumatic  subjects  complete  functional  recovery  is  delayed,  and  often 
never  realized. 

Treatment. — As  this  is  one  of  the  most  frequent  of  fractures,  and 
as  the  results  of  treatment  are,  in  perhaps  the  majority  of  instances, 
imperfect,  it  is  not  surprising  that  such  a  large  number  of  splints 
and  devices  for  treating  this  injury  should  have  been  invented  and 


Fig.  4»i:j. 


-Radiograph  of  case  shown  in  Figs. 
401  and  402. 


FRACTURES  OF  BONKS  OF   THE    UPPER  EXTREMITIES     847 

advocated.  The  secret  of  success  lies  in  early  and  complete  reduction 
of  the  deformity,  when  this  is  possible,  and  not  in  the  kind  of  retention 
apparatus  used.  When  perfectly  reduced  there  is  little  tendency  to  a 
reproduction  of  the  deformity,  and  any  simple  dressing  which  protects 
against  subsequent  injury  and  keeps  the  parts  at  rest  will  meet  the 
indications. 

The  use  of  specially  constructed  splints  to  hold  the  hand  in  some 
abnormal  and  strained  position,  as  the  old-fashioned  pistol  splint, 


Fig.  404. — Author's  dressing  for  Colics'  fracture.    (Radial  view.) 

is  to  be  condemned;  they  are  of  no  value  in  preventing  a  recurrence 
of  the  displacement,  and  often  produce  permanent  weakening  of  the 
wrist  by  stretching  otherwise  uninjured  ligaments  and  tendons. 

In  all  save  the  simplest  cases  reduction  should  be  effected  under 
general  anesthesia,  either  gas  or  ether,  aided  when  possible  by  fluoro- 
scopic examinations. 

Reduction  is  accomplished  best  by  grasping  the  injured  hand  as 
in  the  act  of  shaking  hands.  The  hand  is  then  drawn  strongly  toward 
the  radial  side  to  disengage  the  ulnar  styloid,  which  is  often  caught  in 
the  torn  lateral  ligament.  The  hand  is  then  slowly  brought  back  to 
a  hyperextended  position  to  disengage  the  lower  fragment,  strong 


Fig.  405. — Author's  dressing  for  Colles'  fracture.     (Ulnar  view.) 

traction  being  made  by  the  surgeon,  while  counter-traction  is  main- 
tained by  an  assistant  holding  the  arm  near  the  elbow.  During  this 
maneuvre  the  surgeon  places  the  thumb  over  the  carpal  end  of  the 
lower  fragment  and  two  fingers  under  the  lower  end  of  the  upper 
fragment,  and  by  pressure  backward  and  forward  on  these  two  points, 
and  a  similar  motion  of  the  hand,  breaks  up  the  impaction,  if  present, 
and  pushes  the  lower  fragment  into  place.  If  the  lower  fragment  of 
the  radius  has  been  properly  reduced  the  ulnar  head  will  resume  its 


848  FRACTURES 

normal  position,  unless  it  has  been  forced  through  the  anterior  ligament. 
These  maneuvres  must  be  persisted  in  until  the  normal  position  has 
been  restored,  if  possible,  and  if  .r-ray  examination  shows  imperfect 
reduction  further  attempts  should  be  made.  After  reduction  almost 
any  splint  that  holds  the  forearm  and  wrist  in  slight  flexion  and  mid- 
pronation  will  prevent  recurrence  of  the  deformity  (Figs.  404  and  405). 

The  use  of  a  plaster-of-Paris  palmar  splint  accurately  moulded  to 
the  forearm  and  hand  will  do  away  with  the  necessity  of  pads  and  is 
a  satisfactory  dressing.  When  there  are  much  comminution  and 
considerable  mobility  of  the  fragments  in  restless  children,  and  in 
alcoholic  adults,  with  the  possibility  of  delirium  tremens  developing, 
the  use  of  a  well-padded  circular  plaster  bandage  of  the  forearm  and 
hand  is  to  be  advised.  If  the  soft  parts  are  severely  contused,  and  if 
much  edema  follows  the  injury,  after  reducing  the  displacements,  the 
arm  should  be  treated  for  several  days  by  rest  on  a  pillow  and  wet 
dressings  without  the  use  of  a  retention  apparatus. 

Fractures  of  the  Carpal  Bones. — While  injury  to  the  carpal  bones  is 
comparatively  rare,  it  has  been  found  to  be  of  more  frequent  occur- 
rence than  was  supposed  before  the  general  use  of  the  .r-rays. 

As  the  symptoms  are  often  somewhat  obscure,  and  as  crepitus  may 
be  wanting,  these  injuries  in  the  past  were  generally  regarded  and 
treated  as  bad  sprains  of  the  wrist.  The  classical  paper  of  Codman 
and  Chase,1  however,  has  added  much  to  our  knowledge  of  the  subject, 
and  has  given  us  a  definite  symptomatology  of  the  more  common 
forms  of  carpal  injury. 

Fracture  of  the  scaphoid  is  by  far  the  most  frequent;  that  of  the 
other  bones  comparatively  rare.  This  injury  is  not  infrequently 
associated  with  dislocation  forward  of  the  semilunar,  and  in  these 
cases  the  proximal  fragment  of  the  scaphoid  is  often  carried  forward 
with  the  displaced  semilunar.  In  a  few  instances  the  proximal  frag- 
ment has  been  forced  backward  through  the  dorsal  carpal  ligaments. 

Symptoms. — The  symptoms  of  fracture  of  the  scaphoid  are  the 
history  of  a  trauma  associated  with  forced  hyperextension  or,  rarely, 
flexion  of  the  wrist;  the  presence  of  pain  and  tenderness  in  the  region 
of  the  tabatiere;  swelling  of  the  radial  half  of  the  carpal  region;  and 
painful  limitation  of  extension  and  abduction  of  the  wrist.  The  arrays 
may  be  necessary  to  establish  the  diagnosis,  but  it  must  be  remem- 
bered in  this  connection  that  a  bipartite  variation  in  this  bone  has 
been  demonstrated  by  Professor  Dwight  and  others. 

Treatment. — In  fracture  of  the  scaphoid  without  displacement,  the 
treatment  should  consist  in  immobilization  of  the  parts  for  at  least 
four  weeks.  If  at  the  end  of  this  period  union  has  not  taken  place, 
there  is  little  hope  for  subsequent  repair.  Massage  and  passive  motion, 
however,  in  the  majority  of  instances  will  bring  about  a  good  func- 
tional result.    If  pain  and  stiffness  continue  after  a  reasonable  period 

1  Annals  of  Surgery,  March  and  June,  1905. 


FRACTURES  OF  BONES  OF  THE   UPPER  EXTREMITIES     849 


Anteroposterior  view.  Lateral  view. 

Figs.  406  and  407. — Carpal  injury.     Fracture  of  scaphoid  and  cuneiform  with  anterior 
displacement  of  ulnar  fragment  of  scaphoid  with  semilunar  and  a  portion  of  cuneiform. 


Fig.  408 


Fig.  409 


54 


850 


FRACTURES 


and  are  increased  by  normal  use,  or  if  the  proximal  fragment  is  dis- 
placed, it  should  be  excised. 

Fractures  of  the  other  bones  are  rarely  recognized  except  by  the 
help  of  the  z-rays.  The  same  indications  for  treatment  exist  as  in 
fracture  of  the  scaphoid. 

Fractures  of  the  Metacarpal  Bones. — These  fractures  are  not  infre- 
quent. They  are  generally  caused  by  direct  violence,  as  a  blow  or 
fall  on  the  back  of  the  hand,  or  more  commonly,  from  striking  some 


Fig.  410. — Lateral  view  before  reduction.       Fig.  411. — Same  after  incomplete  reduction. 


hard  body  with  the  closed  fist.  The  latter,  so-called  punch  fractures , 
are  frequently  encountered  in  boxers,  and  are  said  by  Burrows  to 
involve  the  base  of  the  first  and  fifth  metacarpals  and  the  head  or  shaft 
of  the  others.  Two  or  more  of  the  metacarpal  bones  are  often  fractured 
by  the  same  injury. 

Diagnosis. — The  diagnosis  is  generally  easily  established  by  recog- 
nizing the  presence  of  tenderness,  crepitus,  and  false  motion  by  pal- 
pation. If  there  is  considerable  swelling  over  the  back  of  the  hand, 
and  if  the  fracture  is  near  a  joint,  the  signs  may  be  obscured  or  wanting. 


FRACTURES  OF  BONES  OF  THE   UPPER  EXTREMITIES     851 


Localized  tenderness  on  direct  pressure,  and  pain  on  striking  the 
injured  extremity  of  the  bone  while  the  fist  is  closed,  together  with 
localized  pain  on  flexion  and  extension  of  the  corresponding  finger, 
render  the  diagnosis  probable. 

Treatment. — The  treatment  of  these  fractures  should  consist  in 
fixation  of  the  wrist  and  hand,  the  fingers  being  flexed  over  a  firm 
palmer  pad. 

Fractures  of  the  Phalanges. — As  fractures  of  the  phalanges  are 
frequently  due  to  direct  violence,  they  are  often  compound.  In 
simple  fracture  without  displacement 
the  diagnosis  is  not  always  clear,  as 
it  is  often  difficult  to  recognize  or 
produce  independent  motion  in  short 
bones  bounded  above  and  below  by 
very  movable  joints.  Crepitus,  how- 
ever, can  generally  be  obtained  by 
firmly  grasping  and  fixing  the  neigh- 
boring joint  or  joints,  and  making 
strong  lateral  movements. 

Treatment.  —  In  simple  fractures 
without  displacement  or  in  which 
reduction  has  been  effected,  splints 
are  rarely  called  for,  the  only 
treatment  necessary  being  the  appli- 
cation of  a  bulky  dressing  to  avoid 
motion  of  the  part.  The  employment 
in  such  cases  of  a  bandage  made  of 
exceedingly  thin  gutta-percha  tis- 
sue has  been  found  the  most  satis- 
factory dressing.  The  small  roller  is 
first  immersed  in  hot  water,  then 
applied  to  the  fingers  as  an  ordi- 
nary bandage,  and  when  the  part 
is  covered  by  two  or  three  thick- 
nesses of  the  tissue  the  hand  is 
immersed  in  cold  water,  which 
hardens  the  gutta-percha,  making  a 

light  and  sufficiently  firm  cast.  When  the  gutta-percha  tissue  is  not 
available,  two  or  three  layers  of  ordinary  zinc  oxide  adhesive  plaster 
will  answer  the  purpose.  Where  the  displacement  has  been  pro- 
nounced and  where  there  is  a  tendency  to  recurrence,  a  light-moulded 
plaster  splint  applied  to  the  palmar  and  lateral  aspects  of  the  mod- 
erately flexed  finger  will  be  found  very  comfortable  and  effective. 
In  compound  fractures  which  have  become  infected,  amputation  is 
<renerallv  necessary. 


Fig.  412. — Same  after  complete  reduc- 
tion of  semilunar. 


852  FRACTURES 


FRACTURES  OF  THE  BONES  OF  THE  LOWER  EXTREMITIES. 

Femur. — As  in  fractures  of  other  long  bones,  fractures  of  the  femur 
are  divided  into  three  classes:  fractures  of  the  upper  extremity,  fract- 
ures of  the  shaft,  and  fractures  of  the  lower  extremity. 

Fractures  of  the  Upper  Extremity  of  the  Femur  include  fractures  of 
the  head,  extremely  rare  and  generally  associated  with  dislocation; 
fractures  of  the  neck,  very  common,  especially  in  the  aged;  fractures 
of  the  neck  and  great  trochanter;  fractures  of  the  greater  or  lesser 
trochanter,  and  epiphyseal  separations. 

As  fractures  of  the  head  alone  or  those  of  the  greater  or  lesser  tro- 
chanter are  so  rare  as  to  constitute  veritable  surgical  curiosities,  we 
shall  consider  in  this  section  only  fractures  of  the  neck  with  or  without 
involvement  of  the  greater  trochanter. 

It  is  the  opinion  of  most  modern  authorities  that  the  old  classifi- 
cation into  intracapsular  fractures  and  extracapsular  fractures  of  the 
neck  of  the  femur  should  be  abandoned  for  the  following  reasons: 
First,  because  a  study  of  the  attachment  of  the  capsular  ligament  and 
the  synovial  sheath  contained  within  it  will  show  that  while  the 
anterior  and  inferior  portions  of  the  neck  lie  within  the  capsule,  the 
posterior  and  superior  portions  lie  partly  within  and  partly  without 
the  capsule;  that  the  synovial  membrane  does  not  extend  to  the  line 
of  attachment  of  the  capsule  to  the  bone,  but  is  reflected  from  the 
capsule  to  the  bone  at  a  varying  distance  from  the  capsular  attach- 
ment. Many  fractures,  therefore,  lie  partly  within  and  partly  without 
the  capsule,  and  it  is  possible  for  a  fracture  to  be  at  the  same  time 
intracapsular  and  extra-articular.  Second,  because  it  has  been  abun- 
dantly proved  that  many  intracapsular  fractures  unite  readily  under 
favorable  conditions.  Third,  because  it  is  impossible  clinically  to 
differentiate  the  two  varieties.  Fourth,  because  it  has  been  shown 
that  union  in  this  fracture  depends  upon  the  blood  supply  of  the 
upper  fragment,  which  is  received  chiefly  from  periosteal  vessels 
situated  on  the  upper  portion  of  the  neck,  and  that  this  part  of  the 
periosteum  often  remains  untorn  in  both  intracapsular  and  extra- 
capsular fractures  without  great  displacement.  The  classification  of 
these  fractures  into  fractures  through  the  neck  and  fractures  at  the  base 
of  the  neck,  suggested  by  Stimson,  is  far  more  rational,  and  should 
be  generally  adopted.  In  fractures  through  the  neck  the  line  of  fracture 
is  limited  to  the  neck  between  its  attachment  to  the  head  and  shaft. 
Epiphyseal  separations  at  the  junction  of  the  head  and  neck  may 
occur  before  the  seventeenth  year.  In  fracture  at  the  base  of  the  neck 
the  fracture  follows  the  spiral  and  intertrochanteric  lines,  often  with 
fissures  running  into  the  greater  or  lesser  trochanter.  Rarely  the 
line  of  fracture  may  extend  from  the  junction  of  the  lower  part  of  the 
neck  to  the  shaft  and  run  obliquely  upward  and  outward,  leaving  the 
great  trochanter  attached  to  the  neck. 


FRACTURES  OF  BONES  OF  THE  LOWER  EXTREMITIES       853 

In  all  of  these  fractures  more  or  less  impaction  may  occur,  depending 
upon  the  character  and  direction  of  the  fracturing  force. 

While  these  fractures  may  occur  at  any  age,  fully  two-thirds  occur 
after  the  sixtieth  year,  the  predisposing  cause  being  the  bone  atrophy 
of  old  age.  The  injury  which  results  in  these  fractures  in  the  aged 
is  often  surprisingly  slight:  a  fall  upon  the  hip  or  feet,  or  an  effort 
to  prevent  such  a  fall;  slight  rotary  motion  of  the  body,  the  foot  being 
accidentally  arrested;  or  simply  stepping  unexpectedly  to  a  lower 
level,  may  produce  this  fracture.  In  younger  subjects  considerably 
more  violence  is  necessary,  Whitman  has  recently  called  attention 
to  the  fact  that  fracture  of  the  neck  of  the  femur  is  of *f airly  frequent 
occurrence  in  infancy  and  childhood.  The  lesion  is  often  overlooked 
for  the  reason  that  such  injuries  may  produce  only  slight  and  temporary 
disability,  the  child 'walking  about  without  much  pain  within  a  week 
or  two  following  the  trauma.  Such  fractures,  which  are  probably 
incomplete,  are  followed  by  a  progressively  increasing  amount  of 
shortening  and  adduction,  producing  eventually  typical  examples 
of  coxa  vara.  Epiphyseal  separations  or  fractures  involving  a  part 
of  the  epiphyseal  line  occur  occasionally  in  older  children,  but  are 
rarely  encountered  before  the  tenth  year.  As  the  fracture  is  wholly 
within  the  synovial  membrane,  and  as  the  small  upper  fragment  is 
freely  movable,  accurate  reposition  of  the  fragments  is  often  impos- 
sible by  manipulation.  In  these  fractures  also  the  disability  is  often 
surprisingly  slight,  a  large  number  being  diagnosticated  and  treated 
as  contusions  or  the  early  stage  of  hip  disease. 

Diagnosis. — There  is  a  history  of  a  fall  or  other  injury,  with  pain 
in  and  about  the  hip  and  inability  to  use  the  limb.  On  inspection, 
the  patient  lying  on  the  back,  there  will  be  seen  apparent  shortening 
of  the  limb,  eversion  of  the  foot,  slight  flexion  of  the  knee,  and  a 
fulness  about  the  hip.  The  degree  of  eversion  is  best  estimated, 
according  to  Bigelow,  by  the  comparative  ability  to  invert  the  two 
feet.  Exceptionally  inversion  may  be  present  at  first,  due  to  the 
direction  of  the  fracturing  force.  Palpation  will  reveal  the  presence 
of  tenderness  about  the  hip,  relaxation  of  the  supratrochanteric  por- 
tion of  the  fascia  lata,  abnormal  resistance  at  a  point  just  external 
to  the  femoral  vessels,  one  inch  below  Poupart's  ligament  (Henne- 
quin's  sign),  due  to  the  prominent  angle  formed  by  the  two  fragments, 
which  usually  projects  anteriorly. 

Mensuration  will  reveal  an  actual  shortening  of  from  one-half  to 
three  inches.  This  is  ascertained  by  measuring  from  the  anterior 
superior  spinous  process  of  the  ilium  to  the  tip  of  the  inner  malleolus, 
the  legs  being  extended,  parallel  to  and  equidistant  from  the  median 
line  of  the  body;  or  by  measuring  the  perpendicular  distance  from 
the  tip  of  the  great  trochanter  to  a  line  encircling  the  body  on  a  level 
with  the  two  anterior  superior  spinous  processes  (Bryant's  line); 
or  estimating  the  height  of  the  tip  of  the  trochanter  above  a  line 
drawn  from  the  anterior  superior  spine  of  the  ilium  to  the  tuberosity 


854  FRACTURES 

of  the  ischium  (Nekton's  line,  which  normally  passes  over  the  summit 
of  the  trochanter).  The  amount  of  shortening  can  be  roughly  esti- 
mated by  measuring  with  the  thumb  and  finger  of  each  hand  the 
distance  from  the  anterior  superior  spines  to  the  trochanters  of  each 
side. 

Gentle  downward  traction,  or  rotation  of  the  limb,  causes  pain 
and  may  elicit  crepitus.  Palpation  of  the  trochanteric  region  during 
internal  rotation  of  the  limb  may  occasionally  reveal  the  fact  that 
the  trochanter  does  not  rise,  but  rotates  on  the  axis  of  the  shaft. 
Rotation  of  the  trochanter  through  the  normal  arc  does  not,  however, 
exclude  fracture.  Failure  of  the  trochanter  to  rotate  with  the  shaft 
indicates  an  oblique  fracture  through  the  trochanter. 

In  many  cases  following  this  injury  in  an  elderly  person  the 
only  symptoms  are  pain  and  inability  to  use  the  limb;  and  the  only 
signs  slight  eversion  (which  may  be  due  to  simple  contusion)  and 
slight  shortening,  the  shortening  being  within  the  limits  of  normal 
variation.  In  these  doubtful  cases  it  is  far  better  to  assume  that  a 
fracture  is  present  or  to  wait  for  an  .r-ray  examination,  than  to  resort 
to  extensive  movements  of  the  joint  to  elicit  crepitus  and  render  the 
diagnosis  positive,  for  such  movements  not  infrequently  tear  the  peri- 
osteal bridge  containing  the  vessels  which  nourish  the  upper  fragment, 
and  upon  which  repair  of  the  injury  will  depend. 

Prognosis. — A  perfect  result  after  fracture  of  the  neck  of  the  femur 
in  an  elderly  person  is  not  to  be  expected.  By  the  older  imperfect 
methods  of  treatment  non-union  was  common  and  permanent  dis- 
ability the  rule.  While  sufficient  data  is  not  at  hand  to  make  any 
very  positive  statement,  the  results  reported  by  Whitman,  Walker, 
and  others  of  cases  treated  by  the  abduction  method  would  seem 
to  indicate  that  much  better  results  are  to  be  expected  in  the  cases 
where  this  method  can  be  carried  out.  It  must  be  borne  in  mind, 
however,  that  union  cannot  take  place  by  any  method  of  treatment 
if  the  blood  supply  to  the  upper  fragment  is  cut  off,  and  as  we  have 
no  data  upon  which  to  base  an  accurate  opinion  as  to  the  resulting 
condition  of  nutrition  of  the  upper  fragment,  the  possibility  of  non- 
union should  always  be  predicted.  If  there  is  great  shortening,  free 
motion,  and  abundant  crepitus,  the  absence  of  a  periosteal  bridge 
and  consequent  non-union  are  probable.  If,  on  the  other  hand,  the 
shortening  is  slight,  and  there  is  evidence  of  impaction  with  slight 
displacement,  the  prognosis  is  more  favorable.  Under  favorable 
conditions  from  twelve  to  sixteen  wreeks  are  required  to  bring  about 
firm  union. 

Even  when  bony  union  has  taken  place  marked  impairment  of 
function  may  be  occasioned  by  persistent  pain  and  stiffness  of  the 
joint,  due  to  exuberant  callus  and  rheumatic  conditions.  The  ability 
to  walk  without  pain  has  been  observed  when  no  union  has  occurred, 
a  false  joint  being  formed  by  thickening  of  the  surrounding  ligamentous 
structures.    Death  not  infrequently  results  in  the  aged  from  fracture  of 


FRACTURES  OF  BONES  OF  THE  LOWER  EXTREMITIES      855 

the  neck  of  the  femur,  the  causes  being  shock  and  the  development 
of  hypostatic  pneumonia  during  confinement  to  bed.     In  all  cases 

of  fracture  of  the  neck  of  the  femur  in  the  aged  the  joint  should  lie 
protected  by  the  use  of  crutches  for  at  least  eight  months. 

Treat/mitt.  In  cases  which  present  the  evidences  of  impaction — 
moderate  shortening,  limited  motion,  comparatively  little  pain,  and 
no  crepitus — no  effort  should  be  made  either  in  the  examination  or 
subsequent  treatment  to  correct  the  deformity.  The  patient  should 
be  kept  in  bed  and  the  leg  supported  by  sand-bags  or  pillows,  or, 
better,  by  the  application  of  a  long,  well-padded  side-splint  extend- 
ing from  the  axilla  to  the  foot.  In  the  cases  which  do  not  present 
evidences  of  impaction,  or  those  in  which  there  is  considerable  shorten- 
ing with  abnormal  mobility,  pain,  crepitus,  and  muscular  spasm,  an 


Fig.  413. — Whitman's  method  of  reducing  deformity  by  traction  and  abduction. 

effort  should  always  be  made  to  correct  the  shortening  and  to  hold 
the  limb  in  a  position  which  will  insure  contact  of  the  broken  surfaces. 
This  is  accomplished  best  by  the  method  advocated  by  Whitman, 
which  consists  in  complete  abduction  of  both  lower  extremities  and 
retention  of  the  limbs  in  this  position  by  a  plaster-of-Paris  spica, 
extending  from  the  lower  border  of  the  ribs  to  the  toes  on  the  injured 
side  and  to  just  above  the  knee  on  the  sound  side.  To  accomplish 
this  the  patient  should  be  etherized  and  placed  on  a  table,  the  head 
and  upper  part  of  the  trunk  resting  on  an  elevated  platform  made  of 
a  thick  mattress  or  box  covered  with  a  blanket,  and  the  sacral  region 
supported  by  a  hip  rest  (Fig.  413).  Shortening  should  next  be  over- 
come by  traction,  and  both  legs  graduallv  abducted  to  about  45 
degrees.    During  this  maneuvre  the  pelvis  should  be  firmly  held  and 


856 


FRACTURES 


upward  pressure  made  on  the  trochanteric  region,  while  an  assistant 
overcomes  the  outward  rotation  of  the  limb  by  holding  the  foot  in  a 
perpendicular  position.  In  this  position  of  extreme  abduction  the  two 
fragments  are  brought  into  apposition,  and  the  normal  obliquity  of 
the  neck  is  re-established  (Fig.  414).  In  applying  the  plaster  great 
care  should  be  exercised  to  have  an  even  layer  of  sheet  wadding  over 
the  entire  area  to  be  covered,  and  an  extra  layer  of  the  wadding  should 
be  placed  over  the  bony  prominences.  Large  6-inch  plaster  rollers 
should  be  used,  and  the  plaster  carefully  and  snugly  moulded  over 
the  knee  and  foot  to  insure  complete  immobilization  of  the  limb. 
While  this  method  of  treatment  is  the  ideal  one,  and  undoubtedly 


Fig.  414. — The  long  spica  as  applied  for  the  treatment  of  fracture  of  the  neck  of  the 
femur  in  the  adult  at  an  angle  of  abduction  of  45  degrees. 


fulfils  the  indications  better  than  any  other,  in  a  fair  number  of 
instances  in  old,  feeble,  or  very  obese  individuals,  its  employment 
would  be  impracticable,  and  in  these  the  use  of  a  modified  Buck's 
extension  apparatus  is  to  be  advised  (Fig.  415).  Place  the  patient 
on  a  narrow  bed  with  a  hard  mattress  well  supported  so  as  to  present 
a  level  surface.  Traction  straps  of  adhesive  plaster  are  placed  well 
above  the  knee  on  each  side  of  the  leg  and  attached  to  a  foot-board 
below,  from  the  centre  of  which  a  heavy  weight  cord  runs  over  a 
pulley  fastened  to  the  foot  of  the  bed.  The  traction  straps  are  held 
in  place  by  a  bandage,  care  being  taken  to  protect  the  malleoli.  A 
long  T  side-splint  is  placed  along  the  body  and  leg,  from  the  axilla 
to  a  point  six  or  eight  inches  below  the  foot.    This  is  well  padded  and 


FRACTURES  OF  BONES  OF  THE  LOWER  EXTREMITIES       857 

held  in  place  by  a  body-binder  and  several  straps.  The  heel  is  sup- 
ported on  a  small  ring  made  of  raw  cotton  and  a  bandage.  Eversion 
is  corrected  by  pinning  a  strip  of  canton  flannel  along  the  inner  side 
of  the  leg  bandage,  passing  it  under  the  leg  and  over  the  side  splint, 
where  it  is  secured  by  several  tacks.  This  suspends  the  leg,  taking 
pressure  from  the  heel,  and  causes  the  required  inversion  (Fig.  416). 


Fig.  415. — Modified  Buck's  extension  apparatus. 

Another  method  of  treatment  is  by  the  use  of  Hodgen's  suspended 
splint  (Fig.  417),  in  which  the  leg  rests  in  a  muslin  or  canvas  gutter 
supported  by  two  iron  bars  attached  above  by  a  curved  cross-piece 
fitting  the  thigh  and  below  by  a  straight  connecting  rod.  By  this 
apparatus  the  leg  is  raised  from  the  bed  by  a  traction  pulley,  and  any 


Fig.  416. — Appliance  to  overcome  eversion. 


degree  of  extension  or  elevation  can  be  obtained  by  changing  the 
direction  of  the  traction  apparatus.  To  avoid  the  evil  results  of  con- 
finement in  bed,  Phelps  and  others  have  suggested  the  plan  of  treat- 
ing these  cases  by  a  fixation  apparatus  made  of  a  metal  bar  and 
numerous  supporting  straps  similar  to  the  hip-splints  used  in  the  treat- 
ment of  tuberculous  arthritis  of  that  joint  (Fig.  418).    The  treatment 


858 


FRACTURES 


of  this  fracture  in  infants  and  young  children  should  invariably  be  by 
the  abduction  method.  In  these  cases  union  is  generally  prompt  and 
the  functional  result  perfect.  In  epiphyseal  separations,  if  accurate 
reposition  of  the  fragments  cannot  be  effected  by  manipulation  and 
demonstrated  by  the  .r-rays,  open  operation  should  be  performed  and 
the  fragments  accurately  replaced  and  sutured. 

In  cases  of  non-union  in  adults,  operative  intervention  is  to  be 
considered  when  the  general  health  of  the  individual  is  such  as  would 
warrant  a  moderately  severe  operative  procedure,  followed  by  con- 
finement in  bed  for  several  weeks.  Two  methods  of  treatment  are 
to  be  advised :  First,  accurate  readjustment  of  the  fragment  and  fixa- 
tion by  nails  or  bone  pegs;  and  second,  the  production  of  firm,  bony 
ankylosis  between  the  femur  and  pelvis 


Fig.  417. — Hodgen's  suspended  splint.     (Stimson.) 

The  first  procedure  is  indicated  when  the  upper  fragment  is  viable 
and  of  sufficient  size  to  be  held  by  a  nail  or  peg;  the  second,  when 
the  blood  supply  to  the  upper  fragment  has  been  destroyed. 

The  incision  which  best  exposes  the  femoral  neck  is  the  one  advised 
by  Flint,  and  is  as  follows:  The  knife  is  entered  l\  inches  behind  the 
anterior  superior  spinous  process  and  carried  downward  and  back- 
ward to  the  posterior  margin  of  the  trochanter,  then  directly  down- 
ward for  about  5  or  6  inches.  The  posterior  border  of  the  tensor  vagina? 
femoris  is  next  liberated  and  the  fascia  so  divided  as  to  allow  ample 
retraction  of  the  anterior  musculocutaneous  flap.  This  exposes  a 
triangular  area  bounded  by  the  rectus,  gluti  and  vastus  externus,  at 


FRACTURES  OF   BONES  OF   THE  LOWER  EXTREMITIES        859 


the  bottom  of  which  the  femoral  neck  is  found.  The  capsule  is  next 
divided  and  the  condition  of  the  upper  fragrrient  determined.  If  it 
is  viable,  the  fractured  surfaces  are  freshened  by  gentle  curettage, 
and  the  two  fragments  fastened  together  by  a  nail  driven  through 
the  trochanter  neck  and  head  or,  better,  by  a  bone  peg  after  boring  a 
holr  through  these  structures  by  a  bone  drill.  The  length  of  the  bone 
peg  should  be  from  .'U  to  4  inches  in  an  adult.  If  the  upper  fragment 
is  dead,  it  should  be  removed,  the  cavity  of  the  acetabulum  curetted, 
the  ilium  just  above  the  acetabulum  denuded  and  roughened,  the 
distal  neck  fragment  placed  in  the  cavity,  and  retained  by  suture  of 
the  soft  parts  or  by  means  of  a  bone  or  ivory  peg.  If  there  is  no  neck 
fragment,  the  top  of  the  trochanter  is  removed 
and  the  denuded  upper  part  of  the  shaft  placed 
in  the  acetabulum,  after  which  the  trochanteric 
fragment  is  sutured  to  the  junction  of  the  femur 
with  the  upper  rim  of  the  acetabulum,  the  leg 
placed  in  a  position  of  abduction,  the  wound 
closed,  and  a  plaster  spica  applied.1 

Fractures  of  the  Shaft  of  the  Femur. — These 
are  divided  into  fractures  of  the  upper,  middle, 
and  lower  thirds  of  the  bone.  They  may  be 
caused  by  direct  or  indirect  violence,  or  by 
muscular  action,  or  by  a  combination  of  these 
agencies.  They  are  rarely  compound,  and  al- 
though often  accompanied  by  severe  contusion 
and  swelling  of  the  soft  parts,  injury  to  the 
nerve  trunks  and  great  vessels  is  rare.  In 
fractures  of  the  upper  third  of  the  shaft,  the 
line  of  fracture  may  be  transverse  or  oblique, 
the  upper  fragment  is  generally  displaced  up- 
ward and  outward  by  the  action  of  the  iliop- 
soas, and  the  lower  one  slightly  inward  by  the 
adductors.  This  may  also  occur  in  fractures 
of  the  middle  third,  but  in  most  cases  in  this 
region  the  displacement  of  the  fragments  is  in- 
fluenced rather  by  the  direction  of  the  fracturing 

force  than  the  action  of  muscles,  although  the  powerful  muscles 
almost  invariably  act  to  produce  a  considerable  shortening  (Fig.  419). 
In  children  the  direction  of  the  line  of  fracture  in  the  middle  third  is 
generally  transverse;  in  adults  it  may  be  either  transverse,  oblique, 
or  spiral.  In  fracture  of  the  lower  third  the  lower  fragment  is  apt  to 
be  drawn  downward  by  the  action  of  the  gastrocnemius  muscle. 

Diagnosis. — In  healthy  adults  there  is  a  history  of  some  severe 
trauma,  followed  by  acute  pain  in  the  thigh  and  total  inability  to  use 
the  limb.     Xot  infrequently  the  patient  is  conscious  of  a  distinct 

1  For  a  fuller  description  of  these  procedures,  see  article  by  Flint,  Annals  of  Surgery, 
October,  1908. 


Fig. 


418.— Phelps'  hip- 
splint. 


860  FRACTURES 

sound   caused   by   the   breaking  bone.     On    inspection   the  limb   is 
shortened  and  the  thigh  abnormally  curved.    There  may  be  eversion 


Fig.  419. — Fracture  of  the  shaft  of  the  femur. 


Fig.  420. — Fracture  of  the  shaft  of  the  femur.     (Stimson.) 

or  inversion  of  the  foot.    On  palpation,  localized  pain,  mobility,  and 
crepitus  are  easily  obtained    (Fig.  420).     Contraction  of  the  psoas 


FRACTURES  OF  BONES  OF  THE  LOWER  EXTREMITIES       861 

muscle  is  apt  to  occur  from  the  handling,  or  during  the  administra- 
tion of  the  anesthetic,  causing  marked  increase  in  the  deformity. 
In  fractures  high  up  (subtrochanteric)  there  is  a  prominence  a  few 
inches  below  Poupart's  ligament,  caused  by  the  small  upper  fragment 
being  tilted  upward  and  outward.  In  fractures  low  down  (supra- 
condyloid)  there  is  a  bony  prominence  felt  in  the  upper  part  of  the 
popliteal  space  from  the  action  of  the  gastrocnemius  on  the  lower 
fragment 

Prognosis. — While  simple  uncomplicated  fractures  of  the  femur 
usually  unite  in  from  six  to  eight  weeks,  it  should  be  remembered  that 
in  the  aged  this  confinement  may  be  a  source  of  danger.  The  possi- 
bility of  paralysis  from  nerve  injury,  although  remote,  should  be  borne 
in  mind.  A  certain  amount  of  shortening  of  the  limb  commonly  fol- 
lows this  fracture,  due,  in  the  majority  of  instances,  to  overriding  of 
the  fragments.  This  overriding  may  result  in  delayed  union.  Non- 
union is  rare,  but  may  occur,  as  in  the  humerus,  by  the  interposition 
of  muscular  or  fascial  bands  between  the  fractured  ends  of  the  bone. 
In  a  fair  proportion  of  cases  effusion  into  the  knee-joint  follows  fracture 
of  the  femur,  and  may  persist  for  months  after  the  patient  is  up 
and  about,  giving  rise  to  pain,  stiffness,  and  more  or  less  complete 
ankylosis.  In  compound  fractures  of  the  femur  the  danger  to  life  is 
great.  Infection  once  introduced  into  such  a  wound  is  with  difficulty 
controlled;  prolonged  suppuration,  osteomyelitis,  and  general  sepsis 
usually  result. 

Treatment. — Many  fractures  of  the  shaft  of  the  femur  may  be 
treated  by  Buck's  extension  apparatus,  as  described  on  page  857,  with 
the  addition  of  four  or  five  narrow  coaptation  splints  firmly  strapped 
about  the  thigh.  The  weight  should  be  sufficient  to  overcome  the 
resistance  of  the  muscles  and  to  bring  about  full  extension.  In  strong 
adults  from  fifteen  to  twenty  pounds  are  necessary  at  first;  later 
this  may  be  reduced  to  eight  or  ten  pounds.  A  better  form  of  treat- 
ment is  reduction  under  full  anesthesia  with  the  application  of  a 
plaster  spica  from  the  level  of  the  umbilicus  to  the  toes.  In  fractures 
of  the  upper  third  the  tendency  to  displacement  of  the  upper  frag- 
ment should  be  met  with  some  apparatus  which  allows  flexion  at  the 
hip  and  slight  abduction.  Hodgen's  suspended  splint  or  the  double- 
inclined  plane  will  be  found  to  meet  this  indication  in  the  majority 
of  instances.  .In  supracondyloid  fractures  the  deformity  caused  by 
the  tilting  downward  of  the  upper  extremity  of  the  lower  fragment 
must  be  overcome  by  flexion  of  the  knee.  The  double-inclined  plane 
splint  is  to  be  employed  in  these  cases. 

In  children,  fractures  in  the  upper  third  are  treated  best  by  ver- 
tical suspension  of  both  legs  (Fig.  421);  in  all  other  portions  of  the 
bone  by  the  use  of  plaster-of-Paris  spica  from  the  waist-line  to  the 
ankle,  applied  during  full  extension  under  anesthesia.  In  all  cases 
the  reduction  must  be  verified  by  .r-ray  examination  and  if  unsatis- 
factory further  attempts  must  be  made. 


862 


FRACTURES 


Compound  fractures  of  the  femur  should  be  freely  exposed  as  soon 
as  possible  after  the  injury,  all  blood  clots  and  lacerated  tissues  re- 
moved, the  bone  reduced  and  held  in  position  by  a  chromicized  catgut 
suture,  the  wound  thoroughly  cleansed  and  partly  united  with  gener- 
ous drainage.  A  plaster-of-Paris  spica  with  windows  for  drainage 
and  dressings  will  be  found  to  be  the  most  convenient  form  of  reten- 
tion apparatus.  Early  amputation  should  be  resorted  to  if  the  signs 
of  general  sepsis  are  progressive. 

Fractures  of  the  Lower  Extremity  of  the  Femur. — These  are  epiphyseal 
separations,  fractures  of  either  condyle,  and  the  T-fracture  into  the  joint. 

Separations  of  the  lower  epiphysis,  which  may 
occur  before  the  twenty-first  year,  generally 
much  earlier,  are  not  so  very  uncommon. 
They  result  generally  from  severe  violence, 
often  accompanied  by  rotary  motion  of  the 
limb. 

Symptoms. — The  symptoms  are  similar  to 
those  of  a  supracondyloid  fracture,  the  differ- 
ence being  that  in  the  epiphyseal  separation 
the  crepitus  is  soft  and  cartilaginous  rather 
than  bonv. 


Fig.  421. — Vertical    suspen- 
sion in  children.    (Stimson.) 


Fig.  422. 


-Intercondyloid  fracture  of  the  femur. 

I  Bryant.) 


Treatment. — Reduction  is  often  difficult,  and  may  require  open 
operation.  When  reduction  has  been  accomplished,  the  injury  may 
be  treated  on  a  double-inclined  plane  or  by  a  plaster-of-Paris  cast. 

Fracture  of  either  condyle  may  occur  as  the  result  of  direct  violence 
or  some  severe  lateral  strain  at  the  knee. 

Symptoms. — The  symptoms  are  pain,  mobility,  and  crepitus  in  the 
region  of  the  injured  condyle,  with  effusion  into  the  joint.  The  frag- 
ment is  generally  displaced  upward ;  there  is  a  large  range  of  lateral 
movement  at  the  knee. 

Treatment— It  the  fragment  is  easily  reduced,  the  fracture  may  be 
treated  by  a  posterior  splint,  with  cold  applications  to  the  knee  until 


FRACTURES  OF  BONES  OF  THE  LOWER  EXTREMITIES       863 

the  swelling  begins  to  diminish.  After  that  a  plaster-of-Paris  cast 
may  be  applied  or  Hodgen's  splint  used.  If  reduction  is  difficult  or 
if  there  is  a  strong  tendency  to  a  reproduction  of  the  deformity,  open 
operation  is  to  be  advised,  if  the  conditions  are  such  as  to  insure 
perfect  asepsis. 

T-fracture  into  the  Joint  (Fig.  422). — A  fracture  above  and  between 
the  condyles,  the  line  of  separation  of  the  two  condyles  passing  through 
the  intercondyloid  notch;  generally  due  to  some  severe  violence,  and 
is  not  infrequently  compound. 

Symptoms. — When  simple,  the  injury  is  recognized  by  the  evidences 
of  a  supracondyloid  fracture  plus  separate  mobility  of  the  condyles 
and  an  effusion  into  the  joint.  There  is  also  an  increase  in  the  distance 
between  the  condyles,  which  is  often  obscured  by  the  joint-effusion. 
Xot  infrequently  the  fracture  is  comminuted.  Union  under  these 
conditions  is  almost  always  accompanied  by  irregularities  of  the  artic- 
ular surface,  giving  rise  to  imperfect  motion  in  the  joint  or  ankylosis. 

As  in  all  fractures  involving  a  joint,  the  prognosis  should  be  guarded 
regarding  the  functional  result. 

Treatment. — In  the  treatment  of  these  fractures  one  should  bear  in 
mind  the  possibility  of  ankylosis,  and  remember  that  in  this  condi- 
tion the  best  position  of  the  limb  is  one  of  very  slight  flexion.  This 
position  can  best  be  maintained  by  a  plaster-of-Paris  cast.  If  there 
are  much  swelling  and  joint-effusion,  a  well-padded  posterior  splint 
should  be  employed  at  first,  with  an  ice-bag  or  wet  dressing  to  the  knee. 

Operative  Treatment  of  Fractures  of  the  Femur. — The  operative 
treatment  of  fractures  of  the  shaft  of  the  femur  is  being  advocated 
by  some  surgeons  as  a  routine  practice.  The  reasons  advanced  are 
that,  in  the  great  majority  of  cases  treated  by  conservative  methods, 
the  bony  fragments  are  not  accurately  replaced,  and  more  or  less 
overriding  is  the  rule.  This  always  results  in  shortening  of  the  limb 
and  imperfect  function,  and,  in  not  a  few  instances,  in  deformity  and 
non-union. 

The  results  of  operative  treatment,  when  successful,  are  undoubt- 
edly far  better  than  by  non-operative  method,  but  it  must  be  borne 
in  mind  that  operation  in  these  cases  always  carries  with  it  a  small 
risk  of  infection,  which  not  infrequently  results  in  greatly  delayed 
union  and  chronic  osteomyelitis.  The  operation,  therefore,  should 
only  be  undertaken  when  the  surgeon  can  command  well-trained 
assistants  and  conditions  of  perfect  asepsis. 

The  author  advises  operation  in  all  cases  of  fracture  of  the  shaft 
of  the  femur  where  the  fragments  are  separated  by  the  soft  tissues,  as 
evidenced  by  the  inability  to  obtain  crepitus  under  general  anesthesia; 
in  cases  of  fracture  in  the  upper  or  lower  third  of  the  bone,  when 
angulation  of  the  fragments  cannot  be  overcome  by  position  and 
traction;  and  in  all  comminuted  fractures  of  the  lower  extremity, 
where  the  function  of  the  knee-joint  is  likely  to  be  seriously  compro- 
mised.   At  least  five  days  should  elapse  after  the  injury  before  open 


864  FRACTURES 

operation  is  undertaken.  In  fractures  of  the  shaft,  if  a  satisf acton- 
reduction  cannot  be  obtained  under  ether  and  maintained  by  proper 
apparatus,  as  evidenced  by  an  x-ray  plate  taken  with  the  dressings 
in  place,  open  operation  is  indicated,  with  plating  of  the  fragments. 
By  satisfactory  reduction  here  is  meant  one  where  at  least  part  of 
the  fractured  surfaces  are  in  contact,  where  there  is  not  more  than  a 
quarter  of  an  inch  shortening  and  where  the  angular  or  rotary  deform- 
ity is  but  slight.  In  children  under  twelve,  open  reduction  is  indi- 
cated less  frequently  than  in  patients  above  that  age,  because  of  the 
wonderful  way  in  which  nature  rounds  off  projecting  portions  of  bone 
and  compensates  for  shortening  by  more  rapid  growth. 

In  fractures  of  the  lower  extremity,  involving  the  articular  surface, 
operation  with  accurate  apposition  of  the  fragments  is  very  frequently 
indicated.  The  use  of  long  screws  or  bolts  which  penetrate  the  entire 
width  of  the  bone  and  plates  will  prove  of  great  value  in  maintaining 
the  reduction. 

Fractures  of  the  Patella. — The  patella  may  be  broken  by  a  direct 
blow  or  fall  upon  the  bone,  which  generally  produces  a  longitudinal, 
irregular,  or  comminuted  fracture;  or  more  commonly  by  muscular 
action,  a  violent  contraction  of  the  quadriceps  extensor,  the  knee 
being  partly  flexed,  which  produces  a  transverse  fracture  or  one  which 
is  slightly  oblique.  It  is  probable  that  a  combination  of  both  of 
these  agencies  may  be  present  in  certain  cases.  In  the  more  com- 
monly observed  fractures  by  muscular  action,  the  line  of  separation  is 
generally  situated  below  the  middle  of  the  bone,  and  is  usually  accom- 
panied by  lateral  tears  in  the  aponeurosis  of  the  quadriceps  muscle. 
The  upper  fragment  is  drawn  upward  by  the  contraction  of  the  muscle, 
and  this  separation  is  increased  still  further  by  hemorrhage  and  an 
effusion  of  synovial  fluid  in  the  joint. 

Diagnosis. — There  is  a  history  of  a  fall,  with  sudden  pain  in  the 
knee  and  inability  to  use  the  limb.  Occasionally  the  patient  is  able 
to  stand,  but  any  attempt  to  walk  will  generally  be  accompanied  by 
involuntary  sudden  flexion  at  the  knee,  which  causes  him  to  again  fall. 
On  examination,  the  region  of  the  joint  is  found  swollen,  tender  to 
the  touch,  and  painful  on  motion;  the  synovial  cavity  is  distended 
and  the  normal  outlines  are  obliterated;  the  power  of  extension  and 
the  ability  to  raise  the  heel  from  the  bed  are  lost.  Palpation  reveals 
the  presence  of  two  or  more  fragments,  with  a  varying  degree  of 
separation  if  the  fracture  is  transverse;  crepitus  is  rarely  obtained  in 
transverse  fractures  unless  the  separation  is  slight  and  easily  overcome. 

Treatment. — The  conservative,  or  non-operative  treatment  of  frac- 
ture of  the  patella  consists  in  absolute  rest  in  bed,  the  application  of 
a  ham-splint,  and  the  use  of  an  ice-bag  or  evaporating  lotions  to  the 
joint  until  the  effusion  and  evidences  of  inflammation  have  subsided. 
An  effort  should  be  made  to  draw  the  fragments  together  by  means  of 
adhesive  straps  (Fig.  423),  and  to  relax  the  quadriceps  tendon  by 
flexion  at  the  hip,  although  the  value  of  the  latter  procedure  is  question- 


FRACTURES  OF  BONES  OF  THE  LOWER  EXTREMITIES       865 

able.  The  adhesive  straps  should  be  frequently  inspected  and  changed 
as  often  as  they  become  loosened.  At  the  end  of  three  weeks  the  leg 
may  be  encased  in  a  light  plaster  cast  and  the  patient  allowed  up  on 
crutches.  This  cast  should  be  worn  for  six  weeks  more,  after  which  a 
heavy  elastic  knee-cap  or  some  form  of  metal  brace  should  be  worn  for 
at  least  six  months  to  prevent  excessive  movement  at  the  knee.  Mas- 
sage and  passive  motion  should  be  undertaken  as  soon  as  there  is 
evidence  of  good  ligamentous  union  of  the  fragments. 

The  operative  treatment  of  fracture  of  the  patella  should  be  under- 
taken only  by  an  experienced  surgeon  with  trained  assistants,  under 
conditions  of  absolutely  perfect  aseptic  technic.  The  following  method 
is  the  one  at  present  employed :  Preparation  of  the  leg  is  commenced 
forty-eight  hours  before  the  operation,  by  shaving  and  scrubbing 
the  part  with  green  soap  and  hot  water.  A  soap  poultice  is  next 
applied  and  allowed  to  remain  in  place  over  night.  The  following 
morning  the  leg  is  again  scrubbed  for  ten  minutes  with  soap  and  hot 
water,  after  which  it  is  douched  with  ether,  alcohol,  and  bichloride 
solution.    A  wet  dressing  of  mercuric  chloride  (1  to  5000)  is  then  applied 


Fig.  423. — Plaster  straps  applied. 

and  allowed  to  remain  in  place  until  the  patient  is  anesthetized.  On 
the  operating-table  the  dressings  are  removed  and  the  leg  again 
scrubbed  for  one  minute  by  an  assistant  after  thorough  cleansing  of 
the  hands,  after  which  it  is  wiped  with  gauze  sponges  wet  with  ether, 
alcohol,  and  an  alcoholic  solution  of  bichloride  (1  to  2000),  and  finally 
douched  with  sterile  water.  A  curved  transverse  incision  is  then 
made  exposing  the  whole  of  the  patella;  the  clots  and  fragments  of 
torn  periosteum  or  aponeurosis  lying  between  the  fragments  are 
removed,  and  the  joint-cavity  thoroughly  irrigated  with  sterile  salt 
solution.  If  the  fragments  are  easily  approximated,  they  are  held 
in  place  by  suturing  the  periosteum  and  torn  aponeurosis  with  chromi- 
cized  catgut,  with  firm  suture  of  the  lateral  expansion  of  the  aponeurosis 
on  both  sides.  If  this  is  not  sufficient  to  insure  accurate  coaptation, 
the  bone  is  firmly  joined  by  two  sutures  of  heavy  chromicized  catgut 
passed  through  openings  drilled  obliquely  through  the  fragments, 
avoiding  the  articular  surfaces.  The  cutaneous  incision  is  then  united 
with  silkworm-gut  sutures.  Aseptic  dressings  are  then  applied  and 
the  limb  encased  in  a  plaster-of-Paris  cast.  Complete  healing  of  the 
55 


86G  FRACTURES 

wound  should  take  place  under  the  primary  dressing,  which  may  be 
left  in  place  from  one  to  three  weeks  if  there  is  no  evidence  of  infection. 

Prognosis. — Bony  union  is  not  to  be  expected  in  cases  treated  by 
the  conservative  method.  When  the  original  separation  is  slight, 
the  ligamentous  union  may  be  close,  firm,  and  the  functional  result 
perfect.  Generally,  however,  the  fragments  are  separated  by  an 
interval  of  from  one-half  to  two  inches,  and  this  separation  may  be 
increased  as  the  use  of  the  leg  is  resumed.  In  many  cases,  however, 
even  when  the  separation  of  the  fragments  is  considerable,  the  result- 
ing disability  is  slight,  and  practically  no  inconvenience  is  experienced 
by  the  patient.  Occasionally  the  disability  is  great,  necessitating  a 
change  in  the  habits  or  occupation  of  the  individual.  The  results  of 
skilful  operative  treatment,  when  no  infection  occurs,  are  practically 
perfect,  firm  bony  or  close  ligamentous  union  being  the  rule,  with 
perfect  restoration  of  function. 

The  occurrence  of  septic  infection  of  the  knee-joint  following  open 
operation  is  of  the  greatest  prognostic  importance,  for  it  generally 
results  in  complete  and  permanent  ankylosis  of  the  joint,  loss  of  the 
limb  or  the  life  of  the  individual.  As  these  results  outweigh  in  their 
seriousness  any  disability  likely  to  follow  conservative  treatment,  the 
operative  treatment  should  only  be  employed  under  the  conditions 
enumerated  above,  and  after  a  frank  statement  of  the  risks  to  the 
patient  or  his  friends.  Flint,  from  an  analysis  of  150  cases  of  open 
operation  in  fractures  of  the  patella,  has  demonstrated  that  the  dangers 
of  sepsis  are  greatest  during  the  first  five  days  after  the  injury,  and 
that  the  safest  time  to  operate  is  between  the  fifth  and  tenth  day. 

Fractures  of  the  Lower  Leg. — These  fractures  are  common  in  middle 
life,  and  especially  in  men.  They  are  the  result  of  direct  or  indirect 
violence,  and  are  frequently  compound. 

Fractures  of  Both  Bones. — When  due  to  indirect  violence,  fracture 
of  the  tibia  usually  occurs  at  about  the  juncture  of  the  middle  and 
lower  thirds,  that  of  the  fibula  slightly  above  this  point;  when  due 
to  direct  violence,  the  fracture  may  occur  at  any  point,  and  is  often 
comminuted.  The  line  of  fracture  in  the  tibia  is  of  considerable 
importance  in  regard  to  prognosis  and  treatment.  It  is  commonly 
transverse,  but,  as  in  other  long  bones,  it  may  be  oblique  or  irregular. 
In  oblique  fractures  the  direction  is  generally  from  behind  and  above 
downward,  forward  and  somewhat  inward,  making  the  sharp  angle 
of  the  upper  fragment  appear  immediately  beneath  the  skin.  The 
lower  fragment  is  usually  displaced  upward  by  the  muscles  of  the  calf, 
and  when  this  displacement  is  marked  the  sharp  upper  fragment  often 
pierces  the  skin,  rendering  the  fracture  compound.  Spiral  fractures  due 
to  forcible  rotation  of  the  foot,  the  body  being  fixed,  are  occasionally 
seen,  and  present  serious  difficulties  in  their  treatment. 

Fracture  of  the  Tibia  Alone. — Fractures  of  the  upper  extremity  of 
the  tibia  are  comparatively  rare;  they  may  be  transverse  or  oblique, 
extending  into  the  joint.     When  oblique  they  may  be  complicated 


FRACTURES  OF  BONES  OF   THE  LOWER  EXTREMITIES        867 

by  the  interposition  of  a  semilunar  cartilage.  Separation  of  the 
upper  epiphysis  has  been  occasionally  reported.  The  fractures  occur- 
ring in  the  shaft  are  more  common,  and  similar  to  those  observed 
when  both  hones  are  broken.  There  is,  however,  very  little  deformity, 
owing  to  the  splint-like  action  of  the  unbroken  fibula.  Fractur<  of 
the  lower  extremity  alone  are  rare,  although  a  number  of  instances 
i  >f  separation  of  the  lower  epiphysis  have  been  reported. 

Fractures  of  the  Fibula  Alone. — Fractures  of  the  fibula  alone  are 
exceedingly  common  if  we  include  in  this  class  Pott's  fracture,  in  which 
the  internal  lateral  ligament  of  the  ankle  or  the  tip  of  the  internal 
malleolus  is  ruptured.  The  fibula  may  be  broken  in  any  part  of  its 
shaft  by  direct  violence.  When  the  injury  is  due  to  indirect  violence, 
as  by  forcible  inversion  or  eversion  of  the  foot,  the  fracture  always 
occurs  in  the  lower  third,  from  one  to  four  inches  above  the  malleolus. 
Displacement  in  these  fractures  is  not  marked,  except  in  the  case  of 
Pott's  fracture,  in  which  the  deformity  is  very  characteristic.  In 
this  fracture,  which  is  caused  by  violent  eversion  of  the  foot,  alone  or 
combined  with  external  rotation,  there  is  first  a  rupture  of  the  internal 
lateral  ligament  or  a  fracture  of  the  internal  malleolus;  this  allows 
an  outward  dislocation  at  the  ankle,  which  causes  next  a  tearing  apart 
of  the  tibiofibular  attachment,  and  finally  a  fracture  of  the  fibula  just 
above  the  joint  by  forcible  bending  outward  of  the  external  malleolus. 
The  fracture  of  the  fibula  is  generally  transverse,  both  fragments 
forming  an  angle  the  apex  of  which  is  directed  inward  against  the 
tibia.  If  rotation  played  an  important  part  in  the  injury,  the  fibular 
fracture  may  be  oblique,  extending  well  up  the  shaft.  The  force  caus- 
ing this  injury  may  cease  at  any  point  and  occasionally  the  fibula  is 
not  broken,  or  it  may  be  continued,  causing  a  compound  outward 
dislocation  of  the  ankle.  Very  frequently  there  is  associated  with  this 
a  backward  displacement  of  the  foot  at  the  tibiotarsal  joint,  which 
occasionally  may  be  extreme. 

Diagnosis. — Both  legs  should  first  be  inspected.  Shortening,  angu- 
lar deformity,  and  irregularity  in  outline  suggest  a  fracture  of  both 
bones;  eversion  and  prominence  of  the  internal  malleolus,  Pott's 
fracture  (Fig.  424);  abduction  or  adduction  of  the  knee,  a  fracture 
of  the  head  of  the  tibia.  The  subcutaneous  surface  of  the  tibia  should 
next  be  palpated  from  the  knee  to  the  ankle.  This  may  reveal  irregu- 
larities in  outline  and  points  of  tenderness.  The  region  of  the  fibula 
should  then  be  palpated.  This  in  the  lower  third  is  easy,  but  above 
that  point  more  difficult,  owing  to  the  muscular  coverings.  Abnormal 
mobility  may  be  sought  for  at  the  knee,  ankle,  or  along  the  shaft-  of 
the  bones.  Crepitus  is  often  elicited  by  motion  at  the  knee  or  ankle  or 
by  pressure  on  one  or  both  bones  in  the  neighborhood  of  any  point  of 
suspicious  tenderness. 

While  the  presence  of  marked  deformity,  abnormal  mobility,  and 
crepitus  will  always  serve  to  establish  the  diagnosis  of  fracture,  frac- 
tures not  infrequently  occur  without  these  signs.    This  is  partieularly 


868 


FRACTURES 


true  in  fractures  of  the  fibula  near  the  ankle,  where  often  the  only 
signs  are  a  limited  point  of  tenderness  and  pain  on  motion.  An  exam- 
ination by  the  .r-rays  is  always  of  the  greatest  value,  not  only  in 
determining  the  presence  of  fracture  in  these  doubtful  cases,  but  also 
to  reveal  the  direction  of  the  fracture,  number  of  fragments,  and 

character  of  displacement,  especially  in  cases 
accompanied  by  considerable  swelling. 

Prognosis. — In  compound  fractures  of  the 
leg,  especially  if  the  bones  are  comminuted 
and  the  soft  parts  extensively  injured,  the 
prognosis  is  exceedingly  grave.  Simple  frac- 
tures, especially  the  oblique  variety,  not  in- 
frequently become  compound  by  carelessness 
in  handling  and  in  transportation.  In  simple 
fractures  of  one  cr  both  bones  the  prognosis 
is  generally  favorable  if  reduction  is  perfect 
and  can  be  maintained.  Difficulty  in  per- 
manent fixation  of  the  fragments  in  oblique 
fractures  of  the  tibia  is  often  encountered, 
and  results  in  delayed  union  and  shortening. 
Improperly  treated  Pott's  fracture  is  almost 
sure  to  result  in  a  weak  ankle  with  eversion 
and  flat-foot. 

Treatment. — Fractures  of  the  upper  ex- 
tremity of  the  tibia  involving  the  joint 
should  be  reduced  as  soon  as  possible  and 
enveloped  in  a  plaster  bandage  from  the 
upper  thigh  to  the  toes.  This  must  be  cut 
down  on  both  sides  in  case  the  swelling 
should  become  excessive.  If  the  x-rays  show 
an  incomplete  approximation  and  proper 
technic  can  be  observed,  the  fracture  should 
be  exposed  and  the  fragments  held  together 
by  screws,  bolts,  or  plates.  In  transverse 
fractures  of  the  shafts  of  the  tibia  and  fibula, 
or  of  either  bone  alone,  when  there  is  little 
or  no  trauma  of  the  soft  parts,  and  when 
reduction  can  be  effected,  the  immediate 
application  of  a  plaster-of-Paris  cast  or  the 
plaster  posterior  splint  is  to  be  recommended.  In  fractures  by  direct 
violence  when  there  is  extensive  contusion  of  the  soft  parts  with  little 
or  no  displacement  the  leg  may  be  placed  in  a  fracture-box  or  sup- 
ported by  side  splints,  and  a  wet  dressing  of  aluminum  acetate  solu- 
tion applied  until  the  swelling  subsides,  after  which  a  plaster-of-Paris 
splint  should  be  employed. 

Oblique  fractures  of  the  tibia  with  fracture  of  the  fibula,  when 
the  tendency  to  overriding  is  marked,  should  be  treated  by  the  im- 


Fig.  424.  —  Pott's  frac- 
ture: outward  displacement. 
(Stimson.) 


FRACTURES  OF  BONES  OF  THE  LOWER  EXTREMITIES       869 

mediate  application  of  a  plaster  cast,  when  the  condition  of  the  soft 
parts  will  permit,  full  traction  being  maintained  until  the  plaster 
hardens.  In  these  fractures,  which  are  often  exceedingly  difficult  to 
reduce  accurately,  and  which  often  become  displaced  during  the 
application  of  the  plaster  cast,  great  help  is  afforded  by  the  use  of 
the  rluoroscope  during  the  application  of  the  dressing.  It  not  infre- 
quently happens  that  owing  to  the  condition  of  the  soft  parts  these 
oblique  fractures  cannot  be  treated  by  a  plaster  cast  for  several  weeks 
after  receipt  of  the  injury.  In  these  cases  it  is  desirable  to  main- 
tain some  degree  of  traction  to  prevent  union  with  deformity.     The 


Fig.  425. — Continuous  traction  in  fracture  of  the  leg.     (Stimson.) 

short  Desault  splint  will  be  found  useful  under  these  circumstances 
(Fig.  425).  Open  operation  is  indicated  in  shaft  fractures  when  a 
proper  reduction  cannot  be  obtained  by  the  closed  method,  or  where 
the  reduction  cannot  be  maintained.  This  is  especially  true  in  oblique 
and  spiral  fractures.  A  curved  incision  is  made  over  the  antero- 
external  aspect,  and  a  flap  lifted  inward.  After  reduction  a  metal 
plate  is  applied  to  the  outer  side  of  the  tibia. 

In  the  treatment  of  Potts  fracture,  early  reduction  under  ether  is 
of  the  greatest  importance.  If  this  can  be  accomplished  before  the 
excessive  swelling,  a  far  more  accurate  approximation  can  be  accom- 


Fig.  426. — Dupuytren's  splint.     (Gross.) 


plished.  In  order  to  insure  close  union  of  the  broken  internal  malleolus, 
or  of  the  torn  ligament,  as  well  as  complete  reduction  of  the  angular 
deformity  in  the  broken  fibula,  the  foot  should  be  placed  in  a  position 
of  marked  inversion.  At  the  same  time  any  posterior  displacement 
of  the  astragalus  must  be  overcome.  The  Dupuytren  splint  (Fig. 
426)  may  be  used  as  a  temporary  dressing  until  a  properly  fitting  plaster 
splint  can  be  applied. 

Vicious  union  following  Pott's  fracture  results  in  marked  deformity 
and  functional  disability.  For  this  condition  Stimson  advises  the 
following  operation:    Incision  along  the  anterior  border  of  the  fibula, 


870  FRACTURES 

through  which  the  line  of  fracture  is  recognized  and  the  fragments 
separated;  second,  incision  along  inner  side  of  tibia,  downward  in  front 
of  inner  malleolus  as  far  as  the  tubercle  of  the  scaphoid.  The  malleolar 
fragment,  if  united,  is  separated  with  a  chisel  and  mallet,  the  joint 
opened,  and  the  lower  end  of  the  tibia  protruded,  the  astragalus  liber- 
ated from  adhesions  and  replaced,  the  incisions  closed  and  the  parts 
surrounded  by  a  sterile  dressing,  and  held  in  an  overcorrected  position 
by  a  plaster  cast.  "Where  the  pain  and  limitation  of  flexion  are  due 
to  the  posterior  displacement  of  the  tarsus,  so  that  the  anterior  lip 
of  the  tibia  impinges  against  the  neck  of  the  astragalus,  great  relief 
can  be  obtained  by  cutting  away  the  projecting  portion  of  the  tibia. 
An  additional  ten  degrees  of  flexion  will  often  markedly  improve  the 
functional  use  of  the  foot. 

Compound  fractures  should  be  treated  by  free  incisions,  removal 
of  blood  clots,  loose  fragments  of  bone  and  torn  muscle,  thorough 
disinfection  with  hydrogen  peroxide  or  tincture  of  iodine,  after  which 
the  bones  should  be  approximated  and  held,  if  necessary,  by  chromi- 
cized  catgut  sutures,  and  the  wound  partly  closed  with  generous 
drainage.  The  employment  of  a  plaster-of-Paris  cast,  with  windows 
over  the  region  of  the  wound  and  drainage  openings,  is  of  the  greatest 
value  in  the  treatment  of  these  fractures,  saving  the  patient  much 
pain  and  discomfort  during  the  earlier  dressings.  If  no  infection  occurs, 
the  primary  dressings  should  be  left  in  place  for  two  or  more  weeks. 
At  the  end  of  this  time,  if  the  deformity  is  still  sufficiently  marked, 
and  there  is  no  active  infection,  it  is  often  wise  to  expose  the  site  of 
fracture,  reduce  the  fragments,  and  hold  them  in  place  by  a  metal  plate 
applied  to  the  outer  surface  of  the  tibia.  This  should  be  removed  after 
union  is  firm.  In  the  presence  of  a  progressive  infection  not  controlled 
by  local  measures,  amputation  should  be  resorted  to  at  an  early 
period  to  save  life. 

In  cases  of  non-union  persisting  for  six  to  eight  months  in  spite  of 
careful  splinting,  massage,  and  perhaps  the  injection  of  blood,  the 
application  of  an  inlay  graft  is  indicated. 

Fractures  of  the  Bones  of  the  Foot. — Fractures  of  the  bones  of  the 
foot  are  of  fairly  frequent  occurrence,  are  often  accompanied  by 
wounds  of  the  soft  parts,  and  are  generally  due  to  direct  violence. 

Fractures  of  the  Calcaneum  may  be  produced  by  a  fall  upon  the  feet 
from  a  height  or  by  muscular  action  in  falling  upon  the  ball  of  the 
foot.  In  the  first  variety  the  fracture  occurs  generally  in  the  middle 
cr  anterior  portion  of  the  bone  and  is  often  comminuted.  The  simplest 
form  is  the  impaction  of  the  articular  surface  for  the  astragalus.  In 
cases  caused  by  muscular  action  the  fracture  is  apt  to  be  limited  to  the 
posterior  portion  of  the  bone,  and  often  to  the  point  of  attachment  of 
the  Achilles  tendon. 

Fractures  of  the  Astragalus  are  caused  by  falls  upon  the  feet,  the 
bone  being  crushed  between  the  tibia  and  calcaneum,  or  by  forced 
flexion  of  the  foot.    In  the  former  instance  the  fracture  occurs  in  the 


FRACTURES  OF  BONES  OF  fHE  LOWER  EXTREMITIES       871 

body  of  the  bone  and  may  be  comminuted.  In  the  latter  the  fracture 
is  generally  limited  to  the  neck. 

Fractures  of  the  Other  Tarsal  Bones  are  very  rare.  Those  of  the  meta- 
tarsals and  phalanges  are  more  common,  and,  as  in  the  case  of  the 
bones  of  the  hand,  are  frequently  compound. 

The  diagnosis  is  often  difficult  and  usually  depends  on  .?-ray  exami- 
nation. Fractures  of  the  calcaneum  can  generally  be  recognized 
by  local  tenderness,  mobility,  and  crepitus.  If  limited  to  the  posterior 
portion  of  the  bone,  the  fragment  attached  to  the  tendo-Achillis  is 
generally  drawn  upward.  Fractures  of  the  astragalus  may  be  assumed 
if  there  is  localized  pain  on  motion  of  the  foot,  crepitus,  and  inability 
to  stand,  and  if  fracture  of  the  other  neighboring  bones  can  be  excluded. 
In  both  the  foot  is  flattened,  the  heel  thickened,  the  malleoli  nearer 
the  ground,  and  the  normal  outlines  obliterated.  Fractures  of  the 
metatarsal  bones  and  -phalanges  can  generally  be  recognized  by  pal- 
pation. In  all  of  these  fractures  an  z-ray  examination  is  often  neces- 
sary to  arrive  at  a  correct  diagnosis;  in  fact,  in  all  injuries  about  the 
ankle  the  x-rays  should  be  employed  as  a  routine  practice. 

Regarding  prognosis  in  fractures  of  the  tarsal  bones,  it  may  be  said 
that  the  result  of  treatment  is  generally  unsatisfactory.  Ely1  has  shown 
that  a  large  percentage  of  the  cases  have  more  or  less  permanent 
disability.  The  causes  of  the  disability  are  limitation  of  motion  and 
persistent  pain  in  walking.  One  of  the  most  frequent  sources  of  pain 
is  the  presence  of  a  fragment  of  projecting  bone  or  exostosis  in  the  soft 
tissues  of  the  heel ;  another  is  the  formation  of  a  mass  of  callus  beneath 
and  about  the  tip  of  the  external  malleolus,  to  which  attention  has 
recently  been  called  by  Cabot  and  Binney.2 

Treatment. — In  the  treatment  of  fractures  of  the  bones  of  the  foot 
it  is  most  important  to  restore  the  fragments  to  their  normal  positions 
and  hold  them  securely  until  union  has  taken  place,  for  it  is  only  in 
this  way  that  the  normal  arches  can  be  maintained. 

In  fractures  of  the  posterior  portion  of  the  calcaneum,  the  knee 
should  be  flexed  and  ankle  extended  to  allow  the  separated  fragments 
to  become  approximated.  In  fractures  of  the  body  of  the  calcaneum 
and  of  the  astragalus  an  effort  should  be  made  to  break  up  any  impac- 
tion which  may  be  present  and  restore  the  normal  outlines  of  the  bone 
and  shape  of  the  ankle.  This  is  often  greatly  facilitated  by  the  use 
of  the  fluoroscope,  which  allows  the  surgeon  constantly  to  compare 
the  injured  with  the  normal  ankle.  The  best  position  for  all  fractures 
of  the  tarsal  bones,  with,  the  exception  of  those  of  the  posterior  portion 
of  the  calcaneum,  is  in  strong  dorsal  flexion  and  inversion.  Where 
the  fragments  cannot  be  satisfactorily  readjusted  by  manipulation, 
open  operation  is  to  be  advised.  In  fractures  of  the  posterior  portion 
of  the  calcaneum  with  marked  separation  of  the  fragments  by  upward 
traction  of  the  Achilles  tendon,  uniting  the   fragments  by   chromic 

1  Annals  of  Surgery,  January,  1907.  2  Ibid. 


872  FRACTURES 

suture  or  nails  will  insure  practically  a  perfect  result.  In  fractures  of 
the  body  of  the  calcaneum  with  much  comminution  little  can  be  done. 
Astragalectomy  is  often  indicated  for  late  disability.  The  removal  of 
a  projecting  exostosis  on  the  heel  will  often  relieve  a  persistent  pain  in 
walking.  Massage  and  passive  movements  are  useful  in  recent  cases, 
and  should  be  regularly  employed  after  the  third  week. 

The  treatment  of  fracture  of  the  metatarsal  bones  and  phalanges 
should  be  by  rest  and  moulded  gutta-percha  splints  or  a  properly 
applied  plaster  bandage.  In  fracture  of  the  first  and  fifth  metatarsals 
where  there  is  irreducible  and  marked  displacement,  open  reduction  is 
indicated.  Wet  dressings  for  the  first  few  days  after  the  injury  are 
often  necessary  to  subdue  inflammation  of  the  soft  parts  and  joint 
membranes. 


CHAPTER  XXX. 
DISLOCATIONS. 

The  term  dislocation  in  its  surgical  sense  refers  to  a  separation  of 
the  articular  surfaces  of  two  or  more  bones  entering  into  the  forma- 
tion of  a  joint. 

This  separation  is  generally  the  result  of  injury,  and  such  dis- 
locations are  called  traumatic  dislocations;  it  is  occasionally  brought 
about  by  disease,  resulting  in  the  destruction  of  some  or  all  of  the 
tissues  of  the  joint,  after  which  the  bone  is  displaced  by  muscular 
action;  these  dislocations  are  spoken  of  as  pathologic  or  spontaneous 
dislocations:  or  it  may  be  rarely  the  result  of  some  prenatal  defect 
or  malformation,  in  which  case  it  is  characterized  as  a  congenital 
dislocation. 

A  dislocation  is  said  to  be  complete  when  the  articular  surfaces  are 
entirely  separated  from  each  other;  incomplete,  whey  they  remain  at 
some  point  in  contact.  As  in  the  case  of  fractures,  dislocations  may  be 
simple  or  compound;  the  former  when  the  lesion  is  covered  by  unbroken 
skin,  the  latter  when  the  soft  parts  are  lacerated,  creating  an  external 
wound  leading  to  the  joint  cavity.  A  complicated  dislocation  is  one  in 
which  the  trauma  results  in  additional  neighboring  injury,  as  a  fracture 
of  one  of  the  bones  forming  the  joint,  or  injury  to  adjacent  vessels  or 
nerve  trunks. 

The  terms  double,  multiple,  and  symmetric  are  sometimes  employed 
to  describe  dislocations  when  the  injury  results  in  more  than  one 
luxation. 

In  the  classification  of  dislocations  the  nomenclature  follows  no 
definite  system.  In  some  instances  the  name  of  the  joint  is  used  to 
describe  the  dislocation,  as  dislocation  at  the  hip,  shoulder,  elbow; 
in  other  instances  the  distal  bone  is  named,  as  dislocation  of  the  head 
of  the  radius  or  a  phalanx  or  metacarpal  bone;  in  others  the  proximal 
bone  is  named,  as  dislocation  of  the  acromial  end  of  the  clavicle  or 
of  the  lower  extremity  of  the  ulna.  In  describing  the  direction  of  a 
dislocation,  the  terms  anterior,  posterior,  external,  and  internal  are 
employed  at  the  knee,  elbow,  and  a  number  of  other  joints;  in  other 
instances  anatomic  regions  are  used,  as  dorsal,  pubic,  sciatic,  thyroid 
at  the  hip,  subglenoid,  subcoracoid,  etc.,  at  the  shoulder. 

The  term  fracture-dislocation  is  used  when  both  fracture  and  dis- 
location of  one  or  more  of  the  articulating  bones  have  occurred. 

Causation. — The  conditions  which  favor  dislocations,  and  which, 
therefore,  may  be  regarded  as  predisposing  factors,  are:    the  male 


874  DISLOCATIONS 

sex,  on  account  of  greater  exposure  to  injury;  adult  life,  on  account 
of  the  diminished  liability  to  fracture;  injury  to  certain  joints,  on 
account  of  their  large  range  of  motion  and  the  absence  of  supporting 
ligaments,  as  the  shoulder,  which  furnishes  nearly  one-half  of  all 
dislocations;  or  other  joints,  from  their  situation  being  more  exposed 
to  trauma,  as  the  elbow-  and  finger-joints.  Previous  injury  or  disease 
may  predispose  a  joint  to  dislocation  by  causing  relaxation  of  the 
supporting  capsule,  ligaments,  or  muscles.  The  exciting  causes  of 
dislocation  are  direct  or  indirect  violence  and  muscular  action.  As 
an  example  of  direct  injury  causing  dislocation,  may  be  mentioned 
a  fall  upon  the  back  from  a  height,  giving  rise  to  a  dislocation  of  the 
spinal  column ;  indirect  violence  acts  by  a  force  received  on  one  extrem- 
ity of  a  long  bone  being  transmitted  to  a  joint  situated  at  a  distance, 
as  a  fall  on  the  hand  or  elbow  causing  a  dislocation  at  the  shoulder. 
The  shoulder  has  been  dislocated  by  violent  muscular  action  alone, 
as  in  throwing  a  ball  or  stone.  Muscular  action,  however,  is  more 
frequently  a  contributing  cause,  acting  with  direct  or  indirect  violence. 

Pathologic  Anatomy. — Under  certain  conditions  of  disease,  as  when 
a  joint  capsule  has  been  greatly  relaxed  by  distension  wTith  fluid, 
or  the  normal  support  of  muscular  structures  has  been  removed 
by  paralysis,  incomplete  and  even  complete  dislocation  may  occur 
without  rupture  of  any  of  the  periarticular  soft  tissues.  Under 
normal  conditions,  however,  when  a  dislocation  occurs  there  is  more 
or  less  laceration  of  the  synovial  membrane,  capsule,  ligaments, 
and  adjacent  muscular  structures.  In  the  ball-and-socket  joints 
there  is  a  rent  in  the  capsule  through  which  the  head  of  the  bone 
protrudes;  in  the  hinge-joints  the  various  ligaments  are  extensively 
damaged,  and  not  infrequently  the  bony  attachments  of  the  ligaments 
are  separated.  Hemorrhage  is  always  present  from  the  torn  tissues, 
and  may  be  sufficient  to  form  a  distinct  hematoma.  Following  the 
injury  there  is  considerable  inflammatory  reaction,  and  in  unreduced 
dislocations  the  resulting  exudate  becomes  organized  and  is  converted 
into  dense  connective  tissue,  which  often  renders  subsequent  efforts 
at  reduction  ineffectual. 

This  formation  of  dense  fibrous  tissue  will  often  surround  the  head 
of  a  dislocated  bone,  eventually  forming  a  new  socket,  which  may 
later  become  lined  with  a  kind  of  synovial  membrane  allowing  con- 
siderable motion. 

Diagnosis  of  Dislocations  in  General. — The  symptoms  commonly 
present  in  traumatic  dislocation  are  pain,  severe  at  the  time  of  injury, 
continuing  moderately  while  the  luxation  remains  unreduced,  but 
markedly  increased  by  any  motion  of  the  part;  deformity  which  is 
generally  apparent  on  inspection;  shortening  or  lengthening  of  the 
limb,  according  to  the  direction  of  the  displacement,  but  without  change 
in  the  length  of  the  bone;  alteration  of  the  normal  outlines  of  the  joint; 
abnormal  relation  of  the  bony  prominences;  restricted  motion  of  the 
limb;    change  in  the  axis  of  the  displaced  bone;    absence  of  the  head 


TREATMENT  OF  DISLOCATIONS  IN  CENERAL  875 

of  a  bone  from  its  socket,  or  its  presence  in  an  abnormal  position; 
absence  of  a  tendency  to  redisplacement  after  reduction.  The  differ- 
ential diagnosis  between  a  dislocation  and  a  fracture  near  a  joint  is 
often  difficult.  In  general  the  symptoms  which  suggest  dislocation 
are  restricted  motion,  absence  of  crepitus,  and  the  fact  that  the  deform- 
ity is  not  reproduced  after  reduction.  Those  which  suggest  fracture 
are  abnormal  mobility,  bony  crepitus,  and  the  tendency  to  recurrence 
of  the  deformity  after  reduction  unless  the  parts  are  securely  held. 
The  symptoms  common  to  both  injuries  are  pain,  deformity,  oblitera- 
tion of  the  normal  outlines  of  the  joint,  and  a  change  in  the  axis  of 
the  bone. 

It  should  always  be  remembered  that  both  fracture  and  dislocation 
may,  and  frequently  do,  exist  in  the  same  case.  In  spontaneous  dis- 
locations there  is  a  "history  of  previous  paralysis  or  joint  disease,  and 
in  congenital  luxations  the  deformity  is  present  from  birth.  In  all 
doubtful  cases  the  examination  should  be  conducted  under  general 
anesthesia  and  controlled  by  a  fluoroscopic  examination  or  radiograph. 
Treatment. — Three  methods  are  employed  in  the  treatment  of 
recent  dislocations.  These  are  reduction  by  manipulation,  by  exten- 
sion, and  by  open  operation.  Reduction  by  manipulation  consists 
in  executing  certain  movements  of  the  limb  by  which  the  displaced 
extremity  of  the  bone  is  made  to  reach  its  socket  by  the  same  route 
taken  in  its  exit;  the  method  is  chiefly  applicable  to  the  shoulder 
and  hip.  The  method  by  extension  consists  in  the  employment  of 
traction  on  the  limb,  usually  manual,  with  firm  counter-extension  by 
an  assistant.  The  first  effect  of  this  is  to  relax  the  firmly  contracted 
muscles,  after  which  the  bone  often  slips  back  into  position  or  may 
be  easily  replaced  by  manipulation.  Formerly,  when  more  force  was 
required  than  could  be  brought  to  bear  on  the  part  by  manual  trac- 
tion, compound  pulleys  were  employed,  but  today  open  operation 
is  generally  preferred  to  the  use  of  great  force.  Reduction  by  open 
operation  should  be  resorted  to  when  other  methods  fail.  It  should, 
however,  never  be  undertaken  unless  the  conditions  are  such  as  to 
insure  a  thoroughly  aseptic  operation.  Under  favorable  conditions 
the  joint  can  be  freely  exposed  by  incision,  any  bands  of  muscle  or 
fascia  preventing  reduction  divided  or  displaced,  the  bone  replaced, 
the  joint  cavity  thoroughly  irrigated,  the  capsule  and  soft  parts 
united,  and  an  immovable  dressing  applied.  The  question  of  drainage 
should  be  settled  by  the  operator  at  the  time  of  operation,  when 
the  condition  of  the  part  is  known  and  the  perfection  of  technic 
appreciated.     It  is  rarely  necessary. 

In  old  dislocations  the  obstacles  to  reduction  and  restoration  of 
function  consist  in  firm  fibrous  adhesions  holding  the  displaced  bone 
in  its  abnormal  position;  filling  up  of  the  socket  by  fibrous  material, 
which  would  prevent  complete  reduction;  contractions  of  the  attached 
muscles;  and  changes  in  the  articular  surfaces,  as  erosion  or  dis- 
appearance of  the  cartilage,  which,  if  reduction  could  be  accomplished, 


876  DISLOCATIONS 

would  prevent  free  motion  in  the  joint.  The  question  of  attempting 
reduction  in  these  cases  should  always  be  decided  by  the  patient  after 
a  candid  statement  of  the  probabilities  of  improvement  and  the  risks  of 
operation.  It  should  not  be  forgotten,  moreover,  that  a  fair  functional 
result  will  often  follow  the  formation  of  a  false  joint,  and  that  late 
reduction  is  often  followed  by  complete  ankylosis  from  late  changes 
in  the  bony  surfaces. 

Attempts  at  reduction  in  these  cases  by  manipulation  and  extension 
should  not  be  undertaken  after  the  formation  of  firm  adhesions,  as 
the  danger  of  fracture  is  great,  which,  if  it  should  occur,  would  neces- 
sarily diminish  the  chances  of  subsequent  reduction  by  any  means. 
The  only  safe  method  is  by  open  arthrotomy,  removal  of  the  obstruct- 
ing fibrous  material,  loosening  of  the  displaced  extremity  of  the  bone, 
and  replacement  by  means  of  elevators  or  the  McBurney  hook.  The 
subsequent  steps  of  the  operation  are  the  same  as  in  the  case  of  recent 
dislocations.  Gentle  passive  motion  should  be  undertaken  early;  and 
later,  massage,  baths,  and  electricity  will  serve  to  restore  the  function 
of  the  surrounding  muscles.  Excision  of  the  head  of  the  bone,  in  cases 
of  unreduced  dislocation  with  greatly  restricted  motion,  offers,  espe- 
cially in  the  shoulder,  a  fair  chance  for  an  improved  functional  result. 

Compound  dislocations  of  the  larger  joints  are  justly  considered  as 
among  the  most  serious  of  bodily  injuries.  They  generally  outrank 
in  gravity  compound  fractures,  for  the  reason  that  a  relatively  greater 
degree  of  force  is  necessary  for  their  production,  and  the  resulting 
shock  and  laceration  of  neighboring  tissues  add  greatly  to  their 
gravity.  "When  the  injury  to  the  vessels,  nerves,  and  other  soft  parts 
is  beyond  repair,  immediate  amputation  is  to  be  advised;  when 
there  is  a  possibility  of  saving  the  limb,  thorough  disinfection  of  the 
wound,  removal  of  torn  or  bruised  fragments  of  muscle  and  fascia, 
reduction  of  the  dislocation,  with  or  without  excision,  partial  closure 
of  the  wound  with  abundant  drainage  and  an  immovable  dressing,  and 
fixing  the  limb  in  a  favorable  position  for  ankylosis,  are  to  be  recom- 
mended. Later,  evidences  of  infection  call  for  prompt  revision;  and  if 
progressive,  amputation  should  not  be  delayed.  Compound  disloca- 
tions in  the  smaller  joints  present  a  less  serious  outlook,  and  con- 
servative measures  may  safely  be  carried  out  in  the  majority  of 
instances. 

SPECIAL   DISLOCATIONS. 

Dislocation  of  the  Jaw. — Dislocation  of  the  jaw  is  of  fairly  frequent 
occurrence,  and  is  caused  by  opening  the  mouth  widely,  as  in  laughing, 
vomiting,  or  in  dental  procedures;  occasionally  it  is  produced  by  a 
blow  on  the  chin  while  the  jaws  are  separated.  It  is  generally  bilateral, 
although  it  may  occur  on  one  side  only.  When  the  mouth  is  opened, 
the  condyles  of  the  jaw  normally  pass  forward  to  the  articular  emin- 
ences; a  sudden  increase  in  this  movement,  with  strong  contraction 
of  the  external  pterygoid  muscles,  results  in  the  condyles  slipping  over 


SPECIAL  DISLOCATIONS  OF  THE  JAW 


877 


this  eminence  into  the  temporal  fossa.  The  interarticular  fibrocarti- 
lage  is  generally  drawn  forward  with  the  condyle.  A  mild  form  of 
recurring  partial  dislocation  or  subluxation  is  occasionally  seen.  It 
is  usually  unilateral.  After  yawning  or  opening  the  mouth  wide  the 
jaw  will  fail  to  completely  close,  and  there  will  be  a  dull  pain  at  the  site 
of  the  affected  joint.  It  is  due  to  faulty  adjustment  of  the  meniscus 
to  the  movements  of  the  condyle. 

Diagnosis. — In  bilateral  dislocation  the  mouth  is  widely  open,  the 
lower  jaw  projecting  somewhat  forward  (Fig.  427),  the  coronoid 
process  can  be  felt  through  the  mouth  to  be  displaced  forward  under 
the  zygoma,  and  a  hollow  can  be  seen  in  front  of  the  ear.  Speech 
and  swallowing  are  impaired,  and  salivation  is  present.  If  the  dis- 
location has  occurred  on  one  side  only,  there  is  less  deformity  and  the 
chin  is  deviated  toward  the  normal  side. 


Fig.  427. — Bilateral  dislocation  of  the  lower  jaw.     (Hamilton.) 

Treatment. — Reduction  is  generally  easy.  The  surgeon  should 
place  his  thumbs,  protected  with  towelling  or  gauze,  upon  the  last 
molar  tooth  of  each  side,  and  make  firm  pressure  downward  until 
the  muscles  are  relaxed;  he  should  then  press  the  jaw  backward  and 
at  the  same  time  elevate  the  symphysis  by  the  disengaged  fingers. 
After  reduction  it  is  well  to  apply  a  four-tailed  bandage  to  prevent,  for 
a  few  days,  any  excessive  movements  of  the  jaw  until  the  torn  capsule 
has  united. 

Unilateral  subluxation  generally  can  be  reduced  by  direct  inward 
pressure  over  the  affected  condyle.     To  prevent  its  recurrence  the 


878  DISLOCATIONS 

patient  should  school  himself  never  to  open  his  mouth  beyond  a  safe 
distance. 

Dislocations  of  the  Clavicle. — Dislocations  of  the  clavicle  may  occur 
at  either  end.  Dislocations  at  the  sternal  end  may  be  forward,  back- 
ward, or  upward;  dislocations  at  the  acromial  end  may  be  upward  or 
downward.  Of  these,  the  dislocation  forward  of  the  sternal  extremity, 
and  upward  of  the  acromial  extremity,  are  the  commonest.  All  other 
varieties  are  rare. 

Dislocations  of  the  Sternal  End. — These  are  produced  generally  by 
some  force  applied  to  the  tip  of  the  shoulder  forcing  it  violently  back- 
ward, forward,  or  downward,  which  drives  the  sternal  extremity  of 
the  bone  from  its  bed.  Direct  violence  by  blows  or  crushes  may  give 
rise  to  the  backward  variety. 

Diagnosis. — In  all  cases  there  is  a  history  of  injury,  Avith  pain  in 
the  region  of  the  sternoclavicular  joint  and  inability  to  use  the  arm. 
In  forward  dislocation  the  head  of  the  bone  rests  in  front  of  the  sternum, 
forming  a  distinct  prominence  at  the  root  of  the  neck;  the  shoulder  is 
apparently  nearer  the  median  line  than  normal;  the  sternomastoid 
muscle  is  rigid.  In  backward  dislocation  there  is  a  depression  at  the 
point  normally  occupied  by  the  head  of  the  bone;  the  neck  is  rigid; 
the  shoulder  falls  inward.  There  may  be  congestion  of  the  arm, 
dyspnea,  or  dysphagia  from  pressure  on  the  venous  trunks,  trachea,  or 
esophagus.  In  the  upward  variety  the  dislocated  end  of  the  bone  can 
be  distinctly  felt  above  the  sternum,  behind  the  sternal  origin  of  the 
sternomastoid  muscle. 

Treatment. — In  all  these  varieties  reduction  is  generally  easy,  and 
is  effected  by  placing  the  knee  firmly  against  the  spine  between  the 
scapulae  and  with  both  hands  drawing  the  shoulders  backward.  Direct 
pressure  over  the  head  of  the  displaced  bone  will  often  facilitate 
reduction. 

The  classic  retention  dressing  is  a  figure-of-eight  bandage  applied 
posteriorly  to  the  shoulders.  Stimson  advises  holding  the  shoulder 
forward  by  an  anterior  figure-of-eight  or  Velpeau  bandage. 

If  the  tendency  to  displacement  is  marked,  and  especially  if  in 
backward  dislocations  pressure  symptoms  are  unrelieved,  open  opera- 
tion with  suture  or  excision  of  the  head  of  the  bone  is  indicated. 

Dislocations  of  the  Acromial  End. —  Upward  dislocations  are  generally 
produced  by  applications  of  force  to  the  tip  of  the  shoulder  in  a  down- 
ward direction  plus  vigorous  contraction  of  the  trapezius  muscle  which 
draws  the  acromial  extremity  of  the  bone  upward.  If  the  displacement 
is  at  all  marked  it  means  that  the  coracoclavicular  ligament  has  been 
ruptured.  The  increased  distance  between  the  clavicle  and  the  cora- 
coid,  as  seen  in  the  away,  will  demonstrate  this.  In  the  rare  downward 
displacements  the  force  is  usually  applied  from  above  in  a  downward 
direction  to  the  upper  surface  of  the  clavicle.  The  outer  extremity 
of  the  bone  is  displaced  downward,and  slightly  backward,  the  acromion 
often  overriding  it.    Subcoracoid  downward  dislocations  of  the  acromial 


DISLOCATIONS  OF  THE  SPINE 


879 


extremity  of  the  clavicle  have  been  described,  although  their  existence 
is  doubtful. 

Diagnosis. — In  the  common  upward  luxation  the  pain  at  the  time 
of  the  injury  may  be  slight,  and  the  resulting  disability  insignificant, 
but  in  most  instances  voluntary  motion  and  pressure  over  the  dis- 
placed bone  are  accompanied  by  severe  pain,  and  there  is  inability 
to  raise  the  arm  above  the  head.  The  shoulder-tip  is  depressed,  the 
acromial  extremity  of  the  clavicle  projects  upward  and  may  override 
the  acromion,  and,  unless  the  swelling 
is  marked,  its  smooth  articular  facet 
can  be  easily  recognized  by  palpation. 

In  the  downward  variety,  in  addition 
to  the  localized  pain,  there  may  be 
numbness  of  the  arm  from  pressure  on 
the  brachial  plexus.  The  deformity  is 
easily  recognized  by  inspection  or  pal- 
pation. The  clavicle  is  depressed,  the 
acromion  is  prominent,  and  its  articular 
facet  may  often  be  palpated. 

Treatment. — Reduction  in  the  upward 
variety  is  easily  accomplished  in  most 
cases  by  carrying  the  shoulder  upward 
and  backward,  with  pressure  over  the 
displaced  extremity  of  the  bone.  In  this 
variety,  retention  of  the  bone  in  its 
normal  position  is  often  difficult,  but 
is  best  effected  by  the  use  of  Moore's 
figure-of-eight  bandage  from  the  elbow 
to  the  opposite  shoulder,  or  by  Stimson's 
method,  which  consists  in  placing  the 
centre  of  a  long  strip  of  adhesive  plaster 
under  the  flexed  elbow,  and  carrying 
the  ends  upward,  one  in  front  and  one 
behind  the  arm,  and  crossing  them  just 
over  the  acromioclavicular  joint.  Dur- 
ing its  application  the  elbow  should  be 
pushed  forcibly  upward  and  the  clavicle 
downward  (Fig.  428).   In  the  downward 

variety,  after  reduction  the  arm  should  be  fixed  to  the  side  by  a  sling 
and  chest-binder.  If  the  coracoclavicular  ligament  has  been  ruptured 
it  should  be  exposed  and  repaired. 

Dislocations  of  the  Spine. — If  one  examines  the  spinal  column  in  an 
articulated  skeleton,  it  will  be  found  that  in  the  cervical  region  the 
articular  processes  look  generally  upward  and  downward,  and  that  the 
slight  anteroposterior  slope  is  not  sufficient  to  prevent  a  separation 
and  sliding  forward  of  the  upper  vertebra  upon  the  lower  if  sufficient 
force  is  applied.    It  will  also  be  seen  that  an  acute  anterior  flexion  of  the 


Fig.  428. — Stimson  dressing  for  an 
acromioclavicular  dislocation. 


880  DISLOCATIONS 

head  and  neck  would  tend  to  separate  these  articular  processes  and 
produce  such  a  sliding  forward.  In  the  dorsal  and  lumbar  regions,  how- 
ever, the  direction  of  the  articulating  surfaces  is  such  that  this  dis- 
placement could  not  occur  without  a  fracture  of  the  articular  processes 
unless  the  upper  vertebra  was  drawn  vertically  upward  for  a  con- 
siderable distance,  a  condition  which  would  practically  never  result 
from  any  ordinary  violence.  These  conditions  will  serve  to  explain 
the  fact  that  dislocations  of  the  spine  alone  without  fracture  are 
exceedingly  rare,  and  are  practically  limited  to  the  cervical  region. 
The  association  of  dislocation  with  fracture  is  of  frequent  occurrence, 
however;  these  injuries,  which  are  spoken  of  as  fracture-dislocations, 
have  been  described  in  the  section  devoted  to  Fractures  of  the  Spine. 

Dislocations  of  the  vertebra?,  like  fractures,  are  generally  produced 
by  some  force  which  bends  the  spine  beyond  its  normal  limits  of 
motion.  This  bending  may  be  the  result  of  direct  violence,  as  a  blow 
on  the  back  of  the  neck,  or  by  the  indirect  violence  of  a  force  applied 
to  a  distant  point  of  the  vertebral  column,  as  diving  into  shallow 
water  and  striking  the  head  violently  against  the  bottom,  causing  sud- 
den acute  flexion.  Muscular  action  may  also  play  a  part  in  the  pro- 
duction of  dislocation,  as  in  a  sudden  violent  rotary  motion  of  the  head 
during  anteroposterior  or  lateral  flexion. 

Several  varieties  of  dislocation  occur  in  the  cervical  region.  In  the 
great  majority  of  instances  the  upper  vertebra  is  displaced  forward 
on  the  underlying  one.  If  the  articular  processes  on  both  sides  are 
separated,  the  dislocation  is  spoken  of  as  a  bilateral  dislocation;  if 
on  one  side  only,  a  unilateral  dislocation.  The  former  is  almost  always 
produced  by  a  violent  bending  forward  of  the  head  and  neck;  the 
latter  by  extreme  lateral  flexion  alone  or  combined  with  rotation. 

Dislocations  backward,  unilateral  and  bilateral,  have  been  recorded, 
but  are  very  rare.  Bilateral  dislocation  in  opposite  directions — that  is, 
a  displacement  of  the  articular  process  forward  on  one  side  and  back- 
ward on  the  other — has  also  been  recorded.  In  forward  bilateral  dis- 
locations the  ligaments  are  torn,  the  intervertebral  disk  is  lacerated, 
the  articular  processes  of  the  upper  vertebra  lie  in  the  intervertebral 
notches  of  the  lower,  the  cord  is  crushed,  the  surrounding  plexus  of 
veins  is  injured,  giving  rise  to  hemorrhage  into  the  canal,  and  the  nerves 
are  stretched  or  crushed  as  they  emerge  from  the  intervertebral  fora- 
mina. In  unilateral  dislocation  the  deformity  is  less,  and  the  cord 
may  be  simply  stretched  and  not  crushed ;  the  same  is  ,true  in  the 
bilateral  variety  if  the  dislocation  is  not  complete,  as  occasionally 
happens.  In  these  cases  the  articular  surfaces  are  not  entirely  sepa- 
rated from  each  other. 

Diagnosis. — As  in  fractures  of  the  cervical  spine,  there  is  a  history 
of  a  severe  injury  resulting  in  exaggerated  flexion  of  the  vertebral 
column,  followed  generally  by  complete  paraplegia  below  the  point  of 
injury.  There  is  localized  pain  in  the  neck,  which  is  increased  by 
any  motion  of  the  head.     Neuralgic  pains  and  muscular  twitchings 


DISLOCATIONS  OF  THE  SPINE  881 

are  occasionally  observed  over  the  distribution  of  one  or  more  of  the 
spinal  nerves  emerging  from  the  injured  intervertebral  foramina. 

Hyperpyrexia,  inequality  of  the  pupils,  and  localized  vascular 
disturbances,  occur  in  certain  cases,  due  to  sympathetic  irritation. 

In  unilateral  or  incomplete  dislocation  the  cord  injury  may  be 
slight,  and  the  resulting  symptoms  irregular  and  due  simply  to  trac- 
tion on  the  cord  and  its  nerves,  or  to  pressure  from  bone  or  hemor- 
rhage. In  these  cases  the  motor  paralysis  is  generally  more  extensive 
than  the  sensory;  both  may  be  incomplete. 

In  addition  to  the  symptoms  enumerated  above,  examination  will 
reveal  the  presence  of  deformity  and  rigidity  of  the  neck,  with  an 
absence  of  crepitus.  There  is  irregularity  in  the  line  of  the  transverse 
and  spinous  processes.  A  prominence  of  the  dislocated  vertebral 
body  may  often  be  seen  or  felt  at  the  back  of  the  pharynx ;  the  respira- 
tion is  embarrassed  if  the  injury  is  above  the  origin  of  the  phrenics. 
Priapism  is  present  in  some  cases.  Cystitis  and  bed-sores  are  prone 
to  develop  soon  after  the  injury,  and  eventually  give  rise  to  septic- 
symptoms. 

Prognosis. — This  depends  entirely  upon  the  amount  of  injury  to 
the  cord.  If  there  is  evidence  of  a  complete  transverse  crushing 
lesion,  death  is  certain  within  a  few  days,  if  the  injury  is  above  the 
exit  of  the  phrenic  nerve;  at  a  later  period,  if  below  this  point.  In 
incomplete  dislocations,  when  the  injury  to  the  cord  is  slight  or  the 
symptoms  due  to  pressure  or  hemorrhage,  recovery  may  occur. 

Treatment. — In  unilateral  or  incomplete  dislocations,  and  in  all 
other  cases  in  which  there  is  no  evidence  of  a  complete  transverse 
lesion  of  the  cord,  an  attempt  at  reduction  should  be  made.  If  the  cord 
is  crushed,  reduction  will  accomplish  nothing,  as  restoration  of  function 
is  impossible.  On  account  of  a  possible  error  in  estimating  the  degree 
of  injury  to  the  cord,  some  surgeons  advise  that  an  attempt  at  reduc- 
tion be  made  in  every  instance.  The  methods  employed  to  effect 
reduction  in  cervical  dislocations  are  of  two  kinds:  by  manipulation, 
and  by  open  operation. 

The  method  by  manipulation  consists  in  the  employment  of 
vertical  extension,  flexion,  and  rotation.  In  a  case  under  the  observa- 
tion of  the  writer,  a  dislocation  high  up  in  the  cervical  region  was 
readily  reduced  by  simply  placing  one  hand  under  the  patient's  chin, 
the  other  under  the  occiput,  and  exerting  steady  traction  upward,  the 
patient  being  in  the  sitting  position.  The  replacement  was  accom- 
panied by  a  distinct  snap,  such  as  is  often  observed  in  the  replacement 
of  other  dislocated  bones.  In  forward  dislocations  the  surgeon  should 
first  employ  flexion  to  disengage  the  articular  processes,  then  traction 
upward  and  extension  of  the  head.  In  unilateral  dislocations  lateral 
flexion  toward  the  healthy  side  should  precede  upward  traction  and 
rotation.  Counter-extension  is  often  necessary  in  carrying  out  these 
manipulations,  and  is  favored  by  placing  the  patient  on  an  inclined 
plane.  If  reduction  is  not  accomplished  by  these  means,  the  patient 
56 


882  DISLOCATIONS 

should  be  prepared  for  operation,  which  is  carried  out  in  the 
following  manner:  Under  general  anesthesia  the  patient  should  be 
placed  face  downward  on  an  operating-table,  the  head  projecting 
slightly  over  the  end  and  firmly  held  by  an  assistant,  who  later  will 
thus  be  able  to  execute  such  movements  as  are  directed  by  the  surgeon. 
An  incision  six  inches  in  length  is  then  made  in  the  median  line  over  the 
spinous  process,  the  edges  of  the  wound  are  firmly  held  apart  by 
retractors,  and  all  muscular  and  aponeurotic  structures  dissected  free 
from  the  spines,  laminae,  and  transverse  processes.  As  soon  as  this  is 
accomplished  and  the  bleeding  arrested,  the  glistening  articular  facet 
of  the  inferior  vertebra  can  generally  be  seen,  with  the  displaced  articu- 
lar process  of  the  dislocated  vertebra  above.  The  assistant  in  charge 
of  the  head,  under  the  direction  of  the  surgeon,  executes  the  various 
movements  of  flexion,  upward  traction,  rotation,  etc.,  necessary  to 
disengage  the  locked  articular  processes,  after  which  the  surgeon  by 
the  use  of  hooks  and  elevators  can  generally  succeed  in  prying  or 
drawing  the  bone  back  into  place.  The  wound  should  then  be  closed 
with  a  small  drain,  an  antiseptic  dressing  applied,  and  the  head  and 
neck  firmly  held  by  a  plaster-of-Paris  bandage. 

It  should  be  remembered  that  efforts  at  reduction  have  occasion- 
ally caused  sudden  death  when  the  injury  was  located  high  in  the 
cervical  region. 

As  dislocation  unaccompanied  by  fracture  practically  never  occurs 
below  the  cervical  region,  the  reader  is  referred  to  the  section  devoted 
to  Fractures  of  the  Spine  for  a  consideration  of  these  injuries  in  the 
dorsal  and  lumbar  regions. 

Dislocations  of  the  Sternum. — Bony  union  of  the  three  portions  of 
the  sternum  occurs  late  in  life  if  at  all,  rarely  before  the  fortieth  year. 
Before  ossification  takes  place  separations  may  occur  at  the  lines 
of  union,  giving  rise  to  two  varieties  of  dislocation:  those  of  the 
body  from  the  manubrium,  and  those  of  the  ensiform. 

Dislocations  of  the  Body  from  the  Manubrium  are  generally  produced 
by  some  violent  crushing  force,  and  are  often  accompanied  by  other 
injuries. 

The  symptoms  are  localized  pain,  which  is  increased  by  respiratory 
efforts,  and  the  presence  of  an  elevation  of  the  upper  border  of  the 
gladiolus,  which  can  be  easily  palpated  under  the  skin.  This  trans- 
verse ridge  lies  at  the  point  of  junction  of  the  second  costal  cartilages; 
and  as  these  generally  remain  attached  to  the  manubrium,  there  is  on 
either  extremity  of  this  ridge  a  small  depression  caused  by  separation 
of  the  cartilages. 

The  treatment  is  the  same  as  in  fractures  of  the  sternum.  Reduction 
is  accomplished  by  direct  pressure  aided  by  dorsal  flexion  of  the  trunk, 
after  which  the  movements  of  the  chest  should  be  limited  by  a  tight 
binder. 

Dislocations  of  the  Ensiform  are  exceedingly  rare,  and  are  produced 
by  direct  violence  or  tight  lacing.    The  base  of  the  ensiform  may  be 


DISLOCATIONS  OF  THE  SHOULDER  883 

displaced  backward,  or  its  tip  may  be  directed  inward,  toward  the 
spine,  at  right  angles  to  the  body  of  the  sternum. 

The  symptoms  are  pain,  which  is  increased  by  motion  or  taking  food. 
In  several  reported  cases  persistent  vomiting  was  the  most  prominent 
symptom. 

Treatment. — Reduction  is  best  accomplished  by  incision  and  re- 
placement of  the  bone,  with  suture,  if  necessary,  to  prevent  recur- 
rence. 

Dislocations  of  the  Ribs. — A  few  examples  of  dislocation  of  the  head 
of  the  ribs  from  the  vertebral  column  have  been  reported,  generally 
accompanied  by  fractures  of  the  spine  or  other  severe  injuries.  Separa- 
tion of  the  ribs  from  their  costal  cartilages,  or  of  the  costal  cartilages 
from  the  sternum,  or  from  each  other,  has  also  been  occasionally 
observed.  As  these*  injuries  are  similar  in  their  etiology,  symptoma- 
tology, and  treatment  to  fracture  of  the  ribs,  the  reader  is  referred  to 
the  Chapter  on  Fractures  for  their  diagnosis  and  management. 

Dislocations  of  the  Shoulder. — Dislocations  of  the  shoulder  are  the 
most  frequent  of  all  dislocations,  in  fact  statistics  show  that  they 
occur  more  often  than  all  other  dislocations  combined.  The  causes 
of  this  frequency  are,  in  their  order  of  importance:  the  large  range 
of  motion  in  the  joint,  the  frequent  strain  of  injury,  and  the  shallowness 
of  the  glenoid  cavity. 

Causes. — Dislocations  of  the  shoulder  are  caused  both  by  direct 
and  indirect  violence.  Direct  violence  may  cause  dislocation  by  a 
fall  on  the  point  of  the  shoulder,  but  more  commonly  by  a  blow  on 
the  upper  part  of  the  arm  while  it  is  abducted  or  raised  above  the  head, 
the  direction  of  the  blow  being  such  as  to  drive  the  head  of  the  bone 
away  from  the  glenoid  cavity.  Indirect  violence  causes  dislocation 
generally  by  a  fall  on  the  hand  or  elbow.  Muscular  action  not  infre- 
quently acts  as  a  contributing  cause,  as  evidenced  by  the  frequency 
of  dislocations  occurring  during  athletic  sports,  especially  wrestling. 

Shoulder  dislocation  is  essentially  an  injury  of  middle  adult  life, 
the  same  cause  producing  fracture  of  the  clavicle  or  dislocation  of 
the  elbow  in  early  life,  and  not  infrequently  fracture  of  the  neck  of 
the  humerus  in  later  life. 

Varieties. — The  following  are  the  varieties  of  shoulder  dislocation, 
in  the  order  of  their  frequency:  subcoracoid,  subglenoid,  subspinous, 
subclavicular,  and  supracoracoid. 

In  the  subcoracoid  variety  (Fig.  429),  which  is  by  far  the  most  com- 
mon, the  capsule  is  ruptured  anteriorly,  allowing  the  head  of  the 
bone  to  protrude  through  the  rent.  The  head  rests  under  the  coracoid 
process  generally  above  the  tendon  of  the  subscapularis,  although 
the  fibres  of  this  muscle  may  be  ruptured  or  pushed  forward,  embrac- 
ing the  head  of  the  bone.  If  the  articular  surface  of  the  humerus  is 
in  contact  with  the  margin  of  the  glenoid,  this  dislocation  is  often 
spoken  of  as  incomplete;  if  the  head  is  pushed  partly  beyond  the 
coracoid,  the  term  intracoracoid  dislocation  has  been  suggested;    if 


884  DISLOCATIONS 

completely  beyond  the  coracoid,  the  dislocation  should  be  classed  as 
subclavicular. 

In  the  subglenoid  variety  the  lower  portion  of  the  capsule  is  ruptured ; 
the  head  of  the  humerus  rests  below  the  glenoid  fossa,  on  or  in  front  of 
the  axillary  border  of  the  scapula,  below  the  tendon  of  the  subscapularis. 
In  extreme  downward  displacement  of  the  head  of  the  bone  the  arm 
may  remain  erect,  the  elbow  being  usually  flexed  and  the  forearm 
resting  behind  the  head;    this  rare  form  is  described  as  the Ju.ratio 


Fig.   429. — Subcoracoid   dislocation  at  shoulder.     Notice  change  of  axis  of  humerus, 
flattening  of  shoulder  and  prominence  under  coracoid. 

erecta.  Certain  authorities  believe  that  most  dislocations  are  primarily 
subglenoid,  the  injury  being  received  while  the  arm  is  raised  above  the 
head,  and  that  the  head  of  the  bone  originally  lying  beneath  the  glenoid 
fossa  subsequently  assumes  a  position  under  the  coracoid  by  lowering 
the  arm  or  other  active  and  passive  movements. 

In  the  subspinous  variety  the  head  of  the  bone  passes  through  a  rent 
in  the  posterior  portion  of  the  capsule,  and  rests  below  the  spine  of 
the  scapula  between  the  infraspinatus  and  teres  minor  muscles,  covered 
bv  the  deltoid. 


DISLOCATIONS  OF  THE  SHOULDER  885 

The  supracoracoid  variety  is  extremely  rare,  and  is  usually  accom- 
panied by  fracture  of  the  coracoid  or  acromion;  the  head  of  the  bone 
is  displaced  upward  and  rests  upon  the  coraco-acromial  ligament. 

Symptoms  and  Diagnosis. — The  symptoms  of  a  dislocation  of  the 
shoulder  are  pain  and  inability  to  use  the  limb.  The  signs  are,  on 
inspection,  deformity  due  to  flattening  of  the  shoulder,  prominence  of 
the  acromion,  alteration  in  the  axis  of  the  arm,  a  swelling  in  the  region 
of  the  displaced  head  of  the  bone;  on  palpation,  absence  of  the  head  of 
the  bone  from  the  glenoid  fossa,  presence  of  the  head  of  the  bone  in 
some  abnormal  position,  muscular  rigidity  causing  diminished  motion 
of  the  joint,  absence  of  crepitus,  and  inability  to  bring  the  elbow 
in  contact  with  the  chest  when  the  hand  is  placed  on  the  opposite 
shoulder;  on  mensuration  the  limb  is  found  to  be  lengthened  in  the 
subglenoid,  and  shortened  in  all  other  dislocations.  An  x-ray  examina- 
tion is  always  desirable,  not  only  to  show  the  exact  position  of  the  head 
but  demonstrate  the  presence  or  absence  of  associated  fracture,  which 
may  or  may  not  be  suspected. 

Complications. — Aside  from  the  contusions  often  present  from  the 
original  trauma,  complicating  injuries  are  comparatively  rare.  Press- 
ure on  the  nerve  trunks  or  the  larger  vessels  may  give  rise  to  numbness 
and  circulatory  disturbances  in  the  arm;  injury  to  these  structures 
occasions  paralysis  and  hematomata.  Of  the  nerves,  the  circumflex 
is  the  one  most  frequently  affected,  and  the  symptoms,  if  at  all  pro- 
longed, are  probably  due  to  a  neuritis  from  the  trauma  of  the  original 
injury,  or  more  often  to  the  attempts  at  reduction.  Of  the  vessels,  the 
circumflex  and  subscapular  are  the  ones  generally  torn,  and  wounds 
of  the  axillary  artery  and  vein  have  been  reported. 

Laceration  of  the  muscles  attached  to  the  greater  and  lesser  tuber- 
osities, or  fractures  at  the  points  of  their  attachment,  may  occur,  and 
by  their  retraction  produce  a  permanent  weakening  of  the  joint, 
a  tendency  to  habitual  dislocation,  or  an  obstacle  to  reduction  by  their 
interposition  between  the  articular  surfaces.  Fractures  of  the  anatomic 
or  surgical  neck  of  the  humerus  occasionally  occur  as  a  complication 
of  dislocation  at  the  shoulder,  and  present  serious  difficulties  in  treat- 
ment. Fractures  of  the  acromion,  coracoid,  and  glenoid  are  also 
occasionally  present,  the  former  generally  associated  with  supracoracoid 
dislocation. 

Treatment. — Two  methods  are  in  general  use:  reduction  by  extension 
or  traction,  and  reduction  by  manipulation.  The  former  is  the  older; 
the  latter,  the  modern  method. 

Reduction  by  Extension. — The  usual  method  is  to  place  the  patient 
on  a  table  and  make  counter-extension  by  a  sheet  carried  around 
the  thorax  and  firmly  held  by  an  assistant.  The  surgeon  then  grasps 
the  affected  arm  near  the  wrist  and  applies  traction  outward  at  a 
right  angle  with  the  body.  Steady  traction  for  a  few  seconds  will 
generally  cause  the  contracting  muscles  to  relax,  after  which  the  head 
of   the  bone   usually   slips   into   place.     Another   method,   formerly 


886  DISLOCATIONS 

extensively  employed,  is  that  of  the  "heel  in  the  axilla."  The  patient 
lies  upon  his  back  on  the  floor  or  on  a  bed;  the  surgeon  sits  facing  the 
patient  on  his  injured  side,  and  after  removing  his  shoe  places  the  heel 
in  the  axilla,  grasping  the  wrist  of  the  patient  with  his  hands  or  by 
means  of  a  clove-hitch;  steady  traction  is  made  downward,  using  the 
heel  as  a  lever  to  force  the  head  of  the  bone  toward  the  glenoid  cavity. 
The  method  is  often  successful,  but  is  inferior  to  that  of  outward 
traction,  and  is  said  to  be  responsible  for  a  number  of  injuries  to  the 
vessels  and  nerves.  The  method  suggested  by  Stimson  is  often 
successful.  The  patient  lies  upon  the  affected  side  on  a  stretcher 
with  his  arm  projecting  through  an  opening  in  the  canvas  body  and 
hanging  down  in  full  abduction.  A  two-  to  five-pound  weight  is 
attached  to  his  forearm  by  adhesive  plaster.  He  is  allowed  to 
remain  in  this  position  for  even  half  an  hour  if  necessary.  The 
weight  will  gradually  tire  out  the  muscles,  and  the  displaced  head 
then  easily  slips  back  into  place.  When  this  method  is  employed, 
gentle  swinging  of  the  hand  may  aid  the  head  in  re-entering  the 
capsule. 

In  the  rarer  forms  of  dislocation  the  direction  of  the  traction  may 
with  advantage  be  altered  to  meet  the  requirements  of  the  case,  such 
as  traction  upward  in  the  luxatio  erecta  and  downward  in  the  supra- 
coracoid  dislocation. 

Method  by  Manipulation  (Kocher). — place  the  patient  on  a  chair 
or  stool,  flex  the  elbow,  and,  keeping  the  arm  close  to  the  side  of  the 
thorax,  rotate  the  humerus  outward  until  the  flexed  forearm  is  parallel 
with  the  transverse  plane  of  the  body;  then,  holding  the  forearm  in 
this  position,  carry  the  elbow  slowly  upward  along  the  anterior  surface 
of  the  chest  until  it  reaches  a  point  opposite  the  ensiform;  quickly 
rotate  the  forearm  inward  until  the  hand  touches  the  opposite  shoulder 
and  lower  the  elbow.  The  head  of  the  bone  may  slip  into  place 
during  any  of  these  motions  (Figs.  430,  431,  and  432). 

This  method  is  chiefly  applicable  to  the  subcoracoid  variety,  and 
if  uncomplicated,  reduction  is  easily  accomplished  in  the  majority 
of  instances.  It  may  fail,  however,  if  the  displacement  is  markedly 
inward  and  downward,  or  if  the  capsule  is  extensively  lacerated. 
Under  these  conditions  extension  is  to  be  preferred.  While  reduction 
of  dislocations  at  the  shoulder  may  usually  be  accomplished  without 
general  anesthesia,  it  is  frequently  desirable  to  employ  it,  not  only  to 
relieve  the  pain  necessarily  incident  to  the  manipulation,  but  also  to 
overcome  muscular  spasm. 

The  employment  of  forcible  reduction  by  means  of  compound 
pulleys,  especially  in  old  dislocations,  as  suggested  and  practised  by 
the  older  surgeons,  is  not  to  be  recommended.  If  a  recent  disloca- 
tion cannot  be  reduced  by  the  expenditure  of  a  moderate  degree  of 
force,  it  is  because  some  mechanical  obstruction  exists  which  is  best 
removed  by  open  operation. 

If  the  dislocation  is  complicated  by  a  fracture  of  the  neck  of  the 


DISLOCATIONS   OF   THE  SHOULDER 


887 


Fig.  430. — Kocher's  method  of  reduction  of  dislocation  of  shoulder:  first  position. 


Fig.  431. — Kocher's  method:   second  position. 


sss 


DISLOCATIONS 


humerus,  it  should  be  treated  by  open  operation,  reduction  of  the 
upper  fragment  being  accomplished  after  the  parts  are  thoroughly 
exposed,  by  means  of  the  McBurney  hook  (Fig.  433),  or  by  the  use 


Kocher's  method:    third  position. 


of  elevators  and  other  prying  instruments.     In  old  injuries  of  this 
kind  excision  of  the  head  of  the  bone  is  often  necessary. 

In  the  reduction  of  old  dislocations  of  the  shoulder,  one  should 
remember  that  the  resulting  motion  is  often  less  than  that  obtained 


Fig.  433. 


-McBurney's  hook  for  making  traction  upon  the  dislocated  upper  fragment. 
(Stimson.) 


by  allowing  the  head  of  the  bone  to  remain  in  its  abnormal  position, 
where  a  false  joint  generally  forms  and  a  fair  amount  of  motion 
develops.     Moreover,  such  attempts  in  the  presence  of  dense  adhesions 


DISLOCATIONS  OF  THE  ELBOW  889 

not  infrequently  result  in  fracture,  or  injury  to  important  vessels  and 
nerves.  If  such  an  attempt  is  to  be  made,  ether  should  be  given,  and 
the  adhesions  gradually  broken  up  by  various  motions  of  the  shoulder 
until  the  bone  is  freely  movable,  after  which  reduction  may  be 
attempted  by  manipulation  or  extension.  If  the  adhesions  are  not 
readily  broken  up  by  a  moderate  amount  of  force,  or  if  there  is  some 
evident  mechanical  impediment  to  reduction,  an  open  operation  is  to 
be  advised  and  the  procedures  carried  out  under  guidance  of  the  eye. 

After  reduction  has  been  accomplished  the  arm  should  be  kept 
moderately  quiet  for  two  or  three  weeks  until  the  wound  in  the  capsule 
unites.  This  is  accomplished  best  by  the  sling  and  body-binder  at 
first,  and  later  the  sling  only  may  be  used.  Passive  motion  in 
uncomplicated  cases  should  be  begun  after  the  second  or  third  day, 
and  at  the  end  of  a*week  in  operative  cases. 

Complete  restoration  of  function  is  to  be  expected  in  recent  uncom- 
plicated cases.  Regarding  the  amount  of  motion  to  be  obtained 
after  reduction  of  old  or  complicated  dislocations,  the  prognosis 
should  be  guarded.  Much  may  be  accomplished  by  persistent  efforts 
at  passive  or  active  motion,  by  massage,  heat  and  electricity. 

Dislocations  of  the  Elbow. — Dislocations  of  the  elbow  are  of  fre- 
quent occurrence,  especially  in  children.  As  has  been  pointed  out, 
they  are  generally  produced  by  a  fall  on  the  hand,  the  arm  being 
extended,  an  injury  which  in  adult  life  is  likely  to  cause  dislocation 
of  the  shoulder,  or  occasionally  a  fracture  of  the  surgical  neck  of  the 
humerus.  Both  bones  may  be  dislocated  backward,  forward,  inward, 
or  outward;  the  radius  alone  may  be  displaced  backward,  forward, 
or  outward;  the  ulna  backward,  forward,  or  inward.  The  classification 
is  extended  still  further  by  the  use  of  the  terms  complete  and  incomplete 
in  connection  with  any  of  these  varieties,  and  by  describing  a  given 
injury  as  a  combination  of  two  forms,  as  a  dislocation  backward  and 
outward. 

Backward  dislocation  of  both  bones  is  very  common;  all  other  forms 
are  comparatively  rare. 

In  backward  displacements  of  both  bones  the  injury  is  almost 
always  produced  by  a  fall  upon  the  extended  hand.  The  ability  which 
most  children  possess  to  slightly  hyperextend  the  arm  may  be  partly 
responsible  for  the  frequency  of  this  dislocation  in  early  life.  Both 
bones  of  the  forearm  are  displaced  backward,  the  coracoid  process  of 
the  ulna  resting  in  the  olecranon  fossa,  the  head  of  the  radius  behind 
the  external  condyle.  If  the  coracoid  process  still  rests  upon  the 
trochlea,  the  dislocation  may  be  termed  incomplete.  With  this 
injury  there  is  always  considerable  laceration  of  the  ligaments;  the 
coracoid  process  or  the  radial  head  may  be  broken  or  the  brachialis 
anticus  muscle  torn  from  its  attachment. 

In  forward  dislocations,  which  are  extremely  rare,  the  injury  is 
produced  by  a  fall  or  blow  on  the  point  of  the  elbow  while  the  forearm 
is  acutely  flexed,  or  a  blow  upon  the  flexor  aspect  of  the  arm  while 


890 


DISLOCATIONS 


the  elbow  is  flexed  and  the  hand  grasping  some  firm  object.  ( lonsider- 
ablymore  force  is  required  to  produce  this  injury,  and  the  accompany- 
ing laceration  of  the  tissues  is  greater  in  extent.     The  olecranon  may 

lie  wholly  in  front  of  the  condyle-,  or  it>  tip  may  rest  upon  the  articular 
surface. 

In  lateral  dislocations,  of  which  the  inward  is  somewhat  more  com- 
mon, luxation  is  seldom  complete.  In  the  external  variety  the  sigmoid 
cavity  of  the  ulna  re>t>  upon  the  capitellum,  the  radial  head  lies  exter- 
nal to  the  condyle.  In  the  internal  variety  the  sigmoid  cavity  lie-  in 
contact  with  the  extra-articular  portion  of  the  internal  condyle,  and 
the  head  of  the  radius  is  generally  in  front  of  the  articular  surface  and 
somewhat  below  it.  In  mired  dislocations,  backward  and  outward, 
or  backward  and  inward,  the  primary  injury  is  probably  the  backward 
one,  the  lateral  displacement  occurring  secondarily  to  it. 


Fig.  434. — Backward  dislocation  of  radius  and  ulna.     lAshhurst.) 


Dislocations  of  the  ulna  alone  are  extremely  rare,  the  backward 
displacement  being  the  one  most  frequently  reported. 

Dislocations  of  the  head  of  the  radius  are  comparatively  common, 
and  are  often  accompanied  by  fracture  of  the  shaft  of  the  ulna.  The 
forward  displacement  is  commonest;  next  in  frequency  comes  the 
backward;  the  outward  is  very  rare. 

Diagnosis. — In  all  dislocations  of  the  elbow  there  is  a  history  of 
injury  followed  by  localized  pain  and  inability  to  use  the  joint.  In 
backward  dislocations  of  both  bones  the  arm  is  semiflexed  and  stipul- 
ated, the  forearm  appears  shortened  when  viewed  from  in  front,  the 
humerus  appears  shortened  if  viewed  from  behind;  there  is  a  distinct 
prominence  of  the  olecranon,  the  normal  relations  between  it  and  the 
epicondyles  is  lost,  the  articular  surface  of  the  humerus  may  be  felt 


DISLOCATIONS  OF  THE  ELBOW  891 

in  front  of  tlu*  joint  below  the  natural  crease  in  the  skin,  and  the  head 
of  the  radius  may  be  palpated  behind  the  external  condyle  (Fig.  434). 
In  the  rare  forward  displacement  the  arm  is  in  partial  flexion;  the 
olecranon  no  longer  forms  a  prominent  point  on  the  posterior  aspect  of 
the  joint,  the  forearm  is  lengthened,  and  the  displaced  bones  may  be 
readily  felt  in  front  of  the  joint.  In  lateral  dislocations  the  diagnosis 
is  usually  made  without  difficulty,  for  in  the  complete  outward  luxation 
the  deformity  is  so  great  that  it  could  hardly  be  mistaken  for  any  other 
condition,  and  in  partial  lateral  displacements  the  signs  are  generally 
sufficiently  characteristic  to  enable  one  to  arrive  at  a  correct  diagnosis 
in  the  absence  of  great  swelling  or  other  complicating  injury.  Thus 
in  the  external  variety  the  rounded  head  of  the  radius  can  be  felt 
moving  with  rotation  of  the  forearm  to  the  outer  side  of  the  condyle; 
while  in  the  internal' variety  the  olecranon  and  sigmoid  cavity  of  the 
ulna  can  be  readily  appreciated,  lying  to  the  inner  side  of  the  internal 
condyle.  In  each  variety  there  is  a  prominence  above  on  the  opposite 
side  of  the  joint,  formed  by  the  overhanging  condyle  and  articular 
surface  of  the  humerus.  Dislocation  of  the  ulna  alone  may  be  recog- 
nized by  the  altered  relations  of  the  olecranon  and  condyles,  by  the 
presence  of  the  radial  head  in  its  normal  position,  and  by  palpating 
the  olecranon  and  sigmoid  cavity  in  an  abnormal  locality.  Dislocation 
of  the  head  of  the  radius  is  recognized  by  the  history  of  injury,  pain  in 
the  joint,  the  inability  to  flex  the  arm  beyond  a  right  angle  or  to 
supinate  without  pain.  In  the  anterior  variety  the  arm  is  partly 
flexed  and  in  a  position  midway  between  pronation  and  supination; 
the  head  of  the  bone  can  be  felt  in  front  of  the  joint  just  above  the 
external  condyle.  In  the  posterior  variety  there  is  an  outward  inclina- 
tion of  the  arm,  and  the  head  of  the  radius  may  be  felt  posteriorly . 
In  external  displacement  the  joint  is  widened,  the  arm  inclined  out- 
ward, and  the  head  of  the  bone  easily  palpated  to  the  outer  side  and 
above  the  condyle. 

Subluxation  of  the  head  of  the  radius  occurs  frequently  in  young 
children,  and  almost  always  from  lifting  the  child  by  one  hand.  The 
symptoms  are  sudden  pain  and  inability  to  use  the  arm.  The  anatomic 
relations  of  the  joint  appear  normal;  there  is  tenderness  over  the 
head  of  the  radius  with  inability  to  supinate  without  pain.  Other 
motions  are  free  but  very  painful. 

Complications. — Dislocations  of  the  elbow  are  rarely  compound. 
Fractures  of  the  coracoid  process  and  olecranon  are  fairly  common 
complications  of  backward  dislocation.  Fracture  of  the  shaft  of 
the  ulna  is  a  frequent  complication  of  dislocation  of  the  head  of  the 
radius.  The  occurrence  of  fracture  of  the  head  of  the  radius  and 
external  or  internal  condyle  of  the  humerus  has  also  been  observed. 
Injury  of  the  brachial  artery  or  of  the  median  or  ulnar  nerve 
occasionally  occurs. 

Treatment. — The  method  usually  employed  in  the  reduction  of 
backward   dislocations   at   the   elbow  is   the   following:  The   patient 


892  DISLOCATIONS 

is  seated  in  a  chair.  The  surgeon  places  his  foot  upon  the  chair 
and  his  knee  in  the  bend  of  the  elbow.  By  grasping  the  wrist  and 
forcibly  flexing  the  arm  over  the  knee  reduction  is  usually  accomplished. 
Stimson  points  out  that  this  method,  although  generally  successful, 
is  faulty  in  that  it  stretches  or  lacerates  structures  not  ordinarily 
injured  by  the  original  trauma.  He  recommends  steady  traction, 
the  arm  being  extended  until  the  coracoid  process  is  drawn  well  below 
the  olecranon  fossa,  then  forward  pressure  on  the  displaced  bones 
with  gradual  flexion.  If  the  coracoid  process  is  not  readily  disengaged 
by  simple  traction,  slight  pronation,  hyperextension,  or  direct  pressure 
backward  on  the  upper  part  of  the  forearm  will  serve  to  lift  it  out  of 
the  olecranon  fossa. 

In  dislocations  of  the  head  of  the  radius  when  associated  with  fracture 
of  the  ulnar  shaft,  extension  followed  by  flexion  and  direct  pressure  on 
the  head  of  the  bone  will  occasionally  serve  to  effect  reduction.  The 
radial  head  is  either  pulled  down  through  the  orbicular  ligament  or 
the  latter  is  torn  vertically.  In  the  former  case  reduction  cannot  be 
accomplished,  and  in  the  latter  the  ligament  will  probably  not  resume 
its  normal  position.  For  this  reason  it  is  wiser  to  cut  down  and  expose 
the  head  and  the  anterior  portion  of  the  joint.  If  the  ligament  is 
torn  its  ends  can  be  pulled  around  the  radial  neck  and  sutured  in 
position.  If  the  ligament  is  still  intact  and  dorsal  to  the  radial  head 
it  may  be  cut  and  the  two  ends  made  to  pass  around  in  front  of  the 
bone,  where  they  can  be  sutured  in  normal  position.  In  old  unreduced 
cases  it  may  be  necessary  or  wiser  to  remove  the  head  and  neck  of  the 
radius.  In  the  other  rare  forms  of  displacement,  extension  followed 
by  flexion  and  direct  pressure  on  the  displaced  bones  is  the  method 
to  be  recommended.  In  all  dislocations,  especially  if  difficulty  is 
experienced  in  reduction,  general  anesthesia  should  be  used. 

The  after-treatment  should  consist  in  fixation  of  the  joint  by  an 
angular  splint  or  sling  and  body  bandage  until  the  torn  structures 
are  healed.  Passive  motion  should  be  employed  after  the  swelling 
and  pain  have  subsided. 

If  in  backward  dislocations  the  coracoid  process  is  fractured,  the 
arm  should  be  held  in  a  position  of  flexion  to  a  degree  somewhat 
more  than  a  right  angle,  and  passive  motion  should  be  delayed  until 
union  has  taken  place. 

Old  dislocations  occasionally  may  be  reduced  by  first  breaking 
up  the  adhesions  by  forced  flexion  and  extension,  and  then  applying 
strong  traction  and  the  various  methods  employed  in  recent  cases. 
The  writer  saw  a  backward  dislocation  reduced  in  this  manner  seven 
months  after  the  injury.  In  the  majority  of  instances,  however, 
it  is  safer  to  perform  an  open  operation  and  replace  the  bones  under 
guidance  of  the  eye. 

Dislocations  of  the  Wrist. — Inferior  Radio-ulnar  Articulation. — The 
inferior  radio-ulnar  articulation  is  not  infrequently  separated  in  Colles' 
fracture  and  in  injuries  about  the  wrist.     In  these  cases  the  inferior 


DISLOCATIONS  OF  THE  WRIST  893 

extremity  of  the  ulna  is  displaced  outward  and  downward,  as  evidenced 
by  the  increased  distance  between  the  two  styloid  processes.  Forward 
or  backward  dislocations  of  the  inferior  extremity  of  the  ulna  unasso- 
ciated  with  Colles'  fracture  are  rare,  and  are  generally  caused  by  forcible 
pronation  or  supination.  In  these  cases  the  distance  between  the  two 
styloid  processes  is  diminished,  and  the  projecting  extremity  of  the 
ulna  is  readily  recognized  above  or  below  the  radius  and  often  over- 
riding it.  Reduction  is  generally  effected  by  traction  and  pressure 
over  the  displaced  bone,  aided,  if  necessary,  by  pronation  and 
supination.  In  old  unreduced  cases  the  function  of  the  wrist  can  be 
almost  entirely  restored  by  a  subperiosteal  resection  of  the  ulnar  head 
and  neck. 

Dislocations  at  the  Radiocarpal  Articulation. — Dislocations  at  the 
radiocarpal  articulation  are  rare,  and  are  caused  generally  by  falls 
upon  the  palm  or  back  of  the  hand,  the  former  producing  a  dislocation 
backward  of  the  carpus,  the  latter  a  dislocation  forward.  In  the 
backward  dislocation  the  deformity  resembles  that  produced  by  a 
Colles'  fracture.  It  is  to  be  distinguished  from  the  fracture,  however, 
by  the  fact  that  the  normal  relations  exist  between  the  two  styloid 
processes;  that  the  joint  is  not  widened;  that  the  smooth  surface  of 
the  projecting  carpal  bones  may  be  felt  lying  above  the  radius;  and 
by  the  absence  of  crepitus  and  ease  of  reduction.  In  the  forward 
dislocation  the  radius  and  ulna  form  a  prominence  on  the  back  of  the 
wrist,  while  the  displaced  carpus  projects  in  front.  These  dislocations 
are  easily  reduced  by  traction  and  direct  pressure,  after  which  a  splint 
should  be  worn  for  a  week  or  ten  days. 

Dislocations  at  the  mediocarpal  articulation  have  been  reported,  but 
are  exceedingly  rare.  The  separation  takes  place  between  the  first 
and  second  rows  of  the  carpus.  The  hand  with  the  second  row  of 
carpal  bones  may  be  displaced  both  backward  and  forward.  Reduction 
is  generally  easy. 

Dislocations  of  the  individual  bones  of  the  carpus  are  occasionally 
observed.  Of  these,  the  semilunar  is  the  one  most  frequently  dis- 
placed, and  the  dislocation  is  generally  forward.  It  is  not  infrequently 
associated  with  fracture  of  the  scaphoid.  In  these  cases  the  proximal 
fragment  of  the  scaphoid  may  be  displaced  forward  with  the  semilunar 
bone.  The  others  are  rarely  displaced  alone.  These  injuries  are 
generally  produced  by  forced  flexion  or  extension  at  the  wrist;  they  are 
occasionally  compound,  and  reduction  is  often  difficult  or  impossible. 
The  diagnosis  may  be  established  by  observing  the  relations  of  the 
displaced  bone  to  the  radius,  ulna,  metacarpal  bones  or  tendons,  by 
the  shape  of  the  projecting  mass,  or  by  an  .r-ray  examination.  In 
the  semilunar  dislocations,  the  displaced  bone  can  be  felt  on  the 
flexor  aspect  of  the  wrist,  pushing  forward  the  median  nerve  and  the 
flexor  tendons  of  the  fingers  which  are  thereby  rendered  tense,  produc- 
ing flexion  of  the  digits.  The  pain  from  median  pressure  may  be 
very  extreme  and  be  the  most  marked  symptom.     In  the  treatment 


894  DISLOCATIONS 

of  semilunar  dislocations,  the  hand  should  be  hyperextended,  then 
gradually  flexed,  pressure  being  made  upon  the  displaced  bone.  In 
recent  cases  this  maneuvre  often  succeeds.  Reduction  of  the  other 
bones  sometimes  can  be  effected  by  traction  and  pressure  combined 
with  forcible  flexion  and  extension.  Carpal  dislocations  frequently 
are  irreducible.  When  the  semilunar  and  proximal  fragment  of  a 
fractured  scaphoid  are  displaced  forward,  reduction  is  usually  impos- 
sible except  by  open  operation.  Even  with  the  bones  exposed  as  they 
lie  in  the  carpal  canal,  it  often  is  impossible  to  get  them  back  through 
the  rent  in  the  anterior  carpal  ligament  without  too  much  trauma. 
In  such  cases  removal  of  the  two  fragments  will  give  a  very  useful 
and  painless  wrist,  though  the  motion  will  be  restricted.  When  the 
dislocation  is  compound  it  is  always  wiser  to  remove  the  bone. 

Dislocations  at  the  carpometacarpal  articulations  are  exceedingly 
rare.  The  first  metacarpal  bone  is  the  one  most  frequently  displaced, 
and  the  direction  of  the  displacement  is  usually  backward,  caused  by 
some  force  applied  to  the  thenar  eminence.  The  thumb  is  shortened 
and  flexed;  the  proximal  extremity  of  the  metacarpal  bone  rests  upon 
the  trapezium,  forming  a  prominence  between  the  extensor  tendons 
of  the  thumb.  The  trapezium  may  be  felt  on  the  palmar  surface. 
Dislocation  of  most  of  the  other  individual  metacarpal  bones  has  been 
recorded,  as  well  as  two  or  more  together.  In  a  few  instances  the  four 
inner  bones  have  been  displaced  forward  or  backward,  and  one  or  two 
examples  of  luxation  of  all  five  have  been  reported. 

Dislocations  of  the  Bones  of  the  Hand. — Dislocations  at  the  meta- 
carpophalangeal joints  are  more  common  injuries  than  the  preceding, 
and  are  generally  single.  The  thumb  is  the  one  most  frequently 
involved;  next  in  frequency  comes  the  index  finger.  The  others  are 
rare. 

The  anterior  or  glenoid  ligament  of  this  articulation  is  a  firm  car- 
tilaginous plate,  which  is  attached  firmly  to  the  base  of  the  palmar 
surface  of  the  phalanx.  Laterally  it  blends  with  the  capsule  and 
receives  some  of  the  fibres  of  the  lateral  ligament.  Its  proximal 
extremity  is  but  loosely  attached  to  the  metacarpal  shaft,  below 
the  head,  by  a  thin  lax  fold  of  synovial  membrane.  In  extension 
this  plate  moves  over  the  head  of  the  metacarpal.  It  frequently 
has  developed  in  its  substance  a  sesamoid  bone.  In  the  thumb  it 
receives  on  either  side  a  large  portion  of  the  fibres  of  insertion  of  the 
short  thumb  muscles.  When  the  phalanx  slips  back  over  the  meta- 
carpal head  to  a  full  right  angle  it  passes  beyond  a  dead  centre  and 
becomes  locked.  This  constitutes  a  complete  dislocation.  If  the 
phalanx  be  flexed  without  being  pulled  down  over  the  metacarpal 
head  the  latter  will  be  forced  through  or  above  the  proximal  edge  of 
the  anterior  ligament  and  the  latter  be  interposed  between  the  two 
bones.  The  phalanx  now  is  in  the  same  axis  as  the  metacarpal  but  in 
a  posterior  plane.  This  constitutes  a  complex  dislocation.  The  only 
difference  between  a  complex  dislocation  in  the  thumb  and  the  other 


DISLOCATIONS  OF   THE  HAM) 


S<.!.-> 


fingers  is  that  the  short  muscles  attached  to  this  cartilaginous  plate, 
by  their  contractions,  tend  to  hold  the  latter  more  firmly  in  place 
behind  the  metacarpal  head. 

Dislocation  of  i he  first  phalanx  of  the  thumb  backward  on  the  meta- 
carpal bone  is  an  injury  which  has  received  a  great  deal  of  attention 
from  surgeons  on  account  of  the  difficulty  in  the  reduction  of  the  com- 
plex variety.  It  is  far  more  frequent  than  the  similar  condition  in 
the  other  fingers. 

In  order  to  reduce  a  complete  dislocation  at  the  metacarpophalan- 
geal joint  the  phalanx  and  metacarpal  are  grasped  firmly  and  the 


Before  reduction.  After  reduction. 

Figs.  435  and  436. — Complex  dislocation  of  metacarpophalangeal  articulation  of  thumb. 


former  pulled  downward  and  away  from  the  latter,  at  the  same  time 
great  care  must  be  exercised  to  maintain  extension  until  the  anterior 
ligament  can  be  made  to  clear  the  metacarpal  head.  Then  the  phalanx 
is  sharply  flexed  into  its  normal  position.  Unless  this  is  observed  there 
is  great  danger  of  converting  it  into  the  complex  form. 

In  a  complex  dislocation  the  phalanx  must  be  first  extended  to  a 
right  angle  to  tighten  the  anterior  ligament.  It  may  then  be  possible 
by  strong  traction  backward  and  downward  to  disengage  the  glenoid 
ligament  from  its  position  behind  the  metacarpal  head.  If  this  fails 
it  is  necessary  to  make  a  lateral  incision  near  the  palmer  aspect  and 


896  DISLOCATIONS 

pull  this  ligament  forward  with  blunt  hook  or  elevator.  In  the  thumb 
it  may  be  necessary  to  split  the  ligament  in  a  longitudinal  plane. 
Forward  dislocations  at  this  articulation  are  rarer  and  more  easily 
treated.  They  are  generally  caused  by  forcible  overflexion.  The 
phalanx  lies  in  front  of  the  metacarpal  bone,  which  is  seen  to  project 
posteriorly.  Reduction  is  accomplished  by  traction,  flexion,  and 
direct  pressure. 

Difficulty  may  occasionally  be  encountered  in  firmly  grasping  a 
finger  in  order  to  exert  sufficiently  vigorous  traction.  In  these  cases 
the  Levis  splint  may  be  employed  (Fig.  437). 

Dislocations  at  the  first  and  second  phalangeal  joints  are  compara- 
tively common,  and  result  from  injuries  received  in  baseball  and  other 
athletic  sports,  as  well  as  from  blows  and  falls.  The  diagnosis  presents 
no  difficulties  unless  the  parts  are  extensively  bruised  and  swollen. 
Reduction  is  accomplished  by  traction  and  direct  pressure. 

Dislocations  of  the  Hip. — The  hip  is  a  large  ball-and-socket  joint 
of  great  solidity.  It  is  rarely  dislocated.  The  reason  of  its  unusual 
strength  lies  in  the  fact  that  although  the  range  of  its  motion  is  large, 
its  socket  is  deep,  its  ligaments  tough,  and  its  surrounding  muscles 


Fig.  437. — Levis'  extension  apparatus. 

heavy  and  firm.  Another  element  which  serves  to  prevent  the  head 
of  the  bone  from  leaving  its  socket  is  atmospheric  pressure.  The 
acetabular  cavity  is  almost  hemispherical,  and  the  head  of  the  femur 
fits  its  hollow  so  accurately  that  air  cannot  enter  until  its  complete 
removal,  which  requires  a  very  considerable  amount  of  force.  The 
weakest  part  of  the  acetabular  rim  is  below,  owing  to  the  thinness 
of  the  bone  and  the  presence  here  of  the  cotyloid  notch.  The  capsular 
ligament,  which  is  attached  to  the  pelvis  at  the  circumference  of  the 
acetabulum,  and  to  the  femur  at  or  near  the  junction  of  the  neck  with 
the  shaft,  is  thickened  at  several-  points,  forming  the  iliofemoral,  pubo- 
femoral, and  ischiofemoral  ligaments.  Of  these,  the  most  important  is 
the  iliofemoral,  or  Y-ligament  of  Bigelow,  which  passes  from  the  anterior 
inferior  spinous  process,  downward  on  the  capsule,  as  a  thick  band  of 
dense  fibrous  tissue,  dividing  at  about  the  middle  of  the  anterior 
surface  of  the  capsule  into  two  bands,  one  passing  to  the  greater  and 
one  to  the  lesser  trochanter  (Fig.  438).  This  ligament  is  said  by  Bige- 
low to  be  capable  of  sustaining  a  strain  of  from  250  to  750  pounds. 
The  weakest  part  of  the  capsule  is  at  its  inferior  and  posterior  por- 
tion. When  the  thigh  is  flexed,  abducted,  and  rotated  inward,  the 
posterior  inferior  portion  of  the  capsule  is  rendered  tense,  and  if  any 


DISLOCATIONS  OF  THE  HIP 


897 


force  is  then  applied  to  the  body  or  limb  to  increase  this  strain  upon 
the  ligament  it  may  rupture  and  the  head  of  the  bone  be  forced  out 
of  its  socket.  Thus  one  of  the  most  frequent  causes  of  dislocation  at 
the  hip  is  a  blow  from  some  heavy  falling  object  received  on  the  back 
of  a  person  in  a  stooping  position.  It  is  probable  that  in  most  dis- 
locations the  head  of  the  bone  leaves  the  socket  at  this  point,  and  its 
ultimate  location  will  depend  largely  upon  the  direction  of  motion 
in  the  affected  limb  immediately  after  the  receipt  of  the  injury.  Thus 
if  the  limb,  after  the  head  of  the  bone  leaves  the  socket,  is  abducted 
and  rotated  outward,  the  head  will  follow  the  rim  of  the  acetabulum 
in  an  inward  direction  and  lodge 
in  the  thyroid  foramen  or  on  the 
pubis;  whereas  if  the  leg  is  ad- 
ducted  and  rotated  inward,  the 
head  of  the  bone  will  pass  to  the 
outer  side  of  the  acetabular  rim 
and  lodge  in  the  sciatic  notch  or 
on  the  dorsum  of  the  ilium.  Ex- 
aggerated secondary  motion  of  the 
limb  in  either  direction  may  carry 
the  head  of  the  bone  to  a  point 
immediately  above  the  acetabulum. 
That  the  head  of  the  bone  takes 
one  of  these  directions  and  lodges 
generally  at  or  near  a  point  which 
gives  to  the  luxation  the  name  iliac, 
sciatic,  thyroid,  or  pubic,  is  due 
largely  to  the  integrity  of  the  ilio- 
femoral ligament.  If  the  trauma 
is  of  sufficient  severity  to  rupture 
this  band,  the  dislocation  may  be- 
come compound,  or  the  head  of 
the  bone  be  driven  to  some  un- 
usual position,  constituting  one  of 
the  irregular  forms  occasionally 
encountered.  Dislocation  of  the 
hip    is    essentially    an    injury   of 

early  or  middle  adult  life.  It  is  most  frequently  observed  in  indi- 
viduals between  fifteen  and  thirty  years  of  age,  although  cases  have 
been  reported  as  occurring  at  any  age  between  six  months  and 
ninety-one  years.  It  is  far  more  frequent  in  men  than  in  women,  the 
proportion  being  about  8  to  1. 

Classification. — In  spite  of  the  many  elaborate  classifications  which 
have  been  suggested  for  dislocations  of  the  hip,  the  profession  gen- 
erally still  employs  the  old  terms  iliac,  sciatic,  thyroid,  and  pubic,  to 
describe  the  common  varieties.  In  the  writer's  opinion,  it  is  far 
more  important  to  recognize  the  method  of  production  of  these  dif- 
57 


Fig.  438.- 


The  iliofemoral,  or  Y-ligament. 
(Bigelow.) 


898  DISLOCATIONS 

ferent  varieties  and  the  probable  course  taken  by  the  head  of  the  bone 
in  reaching  its  abnormal  location,  than  to  seek  to  establish  a  more 
scientific  classification.  Four  regular  dislocations,  the  iliac,  the  sciatic, 
the  thyroid,  and  the  pubic,  will  therefore  be  described,  and  three 
irregular  forms,  the  supracotyloid,  the  infracotyloid,  and  the  perineal. 

Diagnosis. — In  all  cases  there  is  a  history  of  some  severe  injury  fol- 
lowed by  pain  about  the  joint  and  inability  to  use  the  limb.  Deform- 
ity is  always  present,  its  character  depending  upon  the  variety  of 
the  dislocation.  There  is  greatly  diminished  mobility  at  the  joint, 
and  all  movements  of  the  limb  cause  accentuation  of  the  pain.  True 
bony  crepitus  is  absent,  but  a  sensation  suggesting  crepitus  is  often 
imparted  to  the  hand  by  moving  the  limb,  caused  by  the  rubbing  of 
the  head  of  the  bone  against,  the  torn  muscles  and  ligaments. 

In  addition  to  these,  each  variety  has  its  own  characteristic  signs, 
which  will  be  enumerated  separately. 

Iliac  Dislocation. — The  head  of  the  bone  in  this  variety  rests  upon 
the  dorsum  of  the  ilium  above  the  tendon  of  the  obturator  interims 
muscle.  When  the  patient  rests  in  the  dorsal  position,  the  thigh  will 
be  seen  to  be  partly  flexed,  adducted,  and  inverted;  the  long  axis 
of  the  femur,  if  continued,  would  cross  the  opposite  thigh  at  the 
junction  of  the  middle  with  the  lower  third  (Fig.  439).  Flexion  and 
adduction  are  tolerated  but  painful;  extension  and  abduction  impos- 
sible. The  knee  is  slightly  flexed,  and  the  ball  of  the  great  toe  rests 
often  on  the  dorsum  of  the  opposite  foot.  There  is  considerable  short- 
ening, the  greater  trochanter  lies  above  Nelaton's  line,  the  fascia  lata 
is  relaxed,  and  the  head  of  the  bone  may  often  be  felt  in  its  abnormal 
position.  If  the  capsule  is  extensively  lacerated  and  the  outer  portion 
of  the  Y-hgament  torn,  the  head  of  the  bone  may  lie  immediately 
above  the  acetabulum  and  the  limb  assume  a  position  of  marked 
eversion.    This,  however,  is  extremely  rare. 

Sciatic  Dislocation. — In  this  variety  the  head  of  the  bone  lies  on  the 
ischium  near  the  sciatic  notch,  below  the  tendon  of  the  obturator 
interims.  The  symptoms  in  general  resemble  the  iliac  dislocation,  but 
are  less  marked.  There  are  slight  shortening,  slight  flexion,  slight 
inversion  and  adduction;  the  axis  of  the  affected  thigh,  if  extended, 
would  pass  through  the  opposite  knee.  If  both  thighs  are  brought 
to  a  right  angle  with  the  body,  the  patient  being  in  the  recumbent 
position,  the  shortening  of  the  affected  thigh  is  materially  increased. 

Thyroid  Dislocation. — The  limb  is  lengthened,  abducted,  and 
slightly  everted.  The  trochanter  is  below  Nelaton's  line.  There 
is  slight  flexion  at  the  hip  from  tension  of  the  psoas  and  iliacus.  In 
the  recumbent  position  the  limb  cannot  be  fully  extended,  and  the 
knees  cannot  be  approximated  without  severe  pain.  There  is  spasm 
of  the  adductor  muscles  (Fig.  440). 

Pubic  Dislocation. — The  limb  is  shortened,  abducted,  and  mark- 
edly everted.  The  head  of  the  bone  can  generally  be  felt  internal  to 
the  anterior  inferior  spinous  process,  resting  on  the  horizontal  ramus 


DISLOCATIONS  OF   THE  HIP 


VI!  I 


of  the  pubes;  or,  rarely,  above  it  (suprapubic  variety).  The  hip  is 
flattened ;  the  prominence  normally  formed  by  the  greater  trochanter 
is  absent;  adduction  and  internal  rotation  are  exceedinglv  painful 
(Fig.  441). 

Of  the  rare  irregular  dislocations,  the  supracotyloid  resembles 
somewhat  the  dorsal  with  eversion,  or  the  pubic,  but  it  differs  from 
them  in  that  it  is  caused  by  some  severe  injury  which  forces  the 
head  of  the  bone  directly  upward  through  a  rent  in  the  strong  anterior 
portion  of  the  capsule.     There  is  shortening,  with  marked  eversion 


Fig.   439. — Iliac   disloca- 
tion.    (Tillmanns.) 


Fig.  440.— Thyroid  disloca- 
tion. (Tillmanns.) 


Fig.  441. — Pubic   dislo- 
cation.    (Tillmanns.) 


and  abduction.  The  head  of  the  bone  may  easily  be  palpated  just 
below  the  anterior  superior  spinous  process. 

In  infracotyloid  dislocation  there  are  lengthening  and  generally 
marked  flexion,  with  either  slight  inversion  or  eversion  of  the  foot. 
The  head  of  the  bone  is  directly  below  the  acetabulum  and  rests  on 
the  ischium.  It  is  probably  the  primary  stage  of  many  dislocations 
which  are  subsequently  converted  into  one  or  another  of  the  four 
regular  forms. 

The  perineal  variety  is  exceedingly  rare.     In  it  there  is  extreme 


900  DISLOCATIONS 

abduction  with  flexion.  The  head  of  the  bone  rests  in  the  tissues  of 
the  perineum,  where  it  occasionally  presses  upon  the  urethra,  causing 
retention  of  urine. 

Complications. — Compound  dislocations  of  the  hip  are  exceedingly 
rare.  Fractures  of  the  pelvis  or  of  the  neck  or  shaft  of  the  femur  are 
occasionally  encountered,  the  latter  produced  sometimes  by  attempts 
at  reduction.  Laceration  of  the  femoral  vessels  has  been  reported; 
also  injury  to  the  sciatic  nerve.  Simultaneous  dislocation  of  both 
hips  has  been  recorded  in  a  few  instances. 

Prognosis. — In  recent  cases  reduction  generally  can  be  accomplished 
and  a  good  functional  joint  expected.  In  old  cases  efforts  at  reduc- 
tion are  attended  with  considerable  risk,  chiefly  of  fracture  of  the 
neck  or  shaft  of  the  femur.  The  functional  result  in  old,  unreduced 
dislocations  is  occasionally  fair,  especially  in  the  thyroid  variety,  as 
Nature  will  sometimes  form  a  new  and  comparatively  strong  joint, 
allowing  a  considerable  amount  of  mobility.  In  the  other  varieties 
much  disability  results  from  the  shortening,  limited  motion,  and 
lack  of  parallelism  of  the  limbs. 

Treatment. — In  hip  dislocation,  perhaps  more  than  in  any  other, 
the  rule  should  be  observed  of  causing  the  dislocated  head  of  the  bone 
to  follow  backward  its  path  to  the  socket.  The  methods  of  manipu- 
lation popularized  by  Bigelow,  and  now  generally  practised  by  the 
profession,  have  wholly  replaced  the  older  and  unscientific  procedures, 
formerly  practised,  of  forcible  traction  by  pulleys,  etc. 

Bigelow's  methods  are  carried  out  in  the  following  manner:  The 
patient  should  be  thoroughly  anesthetized  and  placed  on  his  back  on 
the  floor;  the  pelvis  should  be  steadied  by  an  assistant.  The  sur- 
geon grasps  the  ankle  of  the  affected  limb  with  one  hand  and  the 
knee  with  the  other.  The  leg  is  then  flexed  to  a  right  angle  with 
the  thigh,  and  the  thigh  to  a  right  angle  with  the  body.  In  the  pos- 
terior displacements  the  thigh  is  then  further  flexed,  adducted,  and 
rotated  inward;  the  knee  is  then  circumducted  externally,  and  while 
this  is  being  done  direct  sudden  upward  traction  is  made,  after  which 
the  leg  is  extended  and  brought  to  the  floor.  In  the  anterior  dis- 
placements the  thigh  is  flexed  and  abducted,  then  circumducted 
internally,  with  upward  traction  and  rotation,  and  finally  fully 
extended.  In  the  rare  dorsal  dislocations  with  eversion,  the  displace- 
ment should  first  be  converted  into  a  regular  dorsal  dislocation  with 
inversion  by  flexion  and  inward  rotation,  then  replaced  by  the  method 
just  described  for  dorsal  dislocations,  or  simply  by  upward  traction 
in  the  flexed  position. 

In  irregular  dislocations  with  extensive  laceration  of  the  capsule, 
direct  traction  upward  with  the  thigh  flexed  at  a  right  angle  with  the 
body,  and  direct  pressure  toward  the  acetabulum  on  the  displaced 
head  of  the  bone,  will  usually  succeed. 

Dislocations  of  the  Patella. — The  patella  may  be  dislocated  outward, 
inward,  and  by  rotation  on  its  longitudinal  axis. 


DISLOCATIONS  OF  THE  KNEE  901 

In  the  outward  variety,  which  is  the  commonest,  the  patella  lies  to 
the  outer  side  of  the  external  condyle.  If  unaccompanied  by  rotation, 
its  inner  edge  only  is  in  contact  with  the  condyle.  Generally,  however, 
a  certain  degree  of  external  or  internal  rotation  is  present,  which 
allows  either  its  anterior  or  posterior  surface  to  come  into  contact 
with  the  condyle.  It  is  caused  by  direct  violence,  as  a  blow  on  the 
inner  edge  of  the  bone,  or  by  muscular  action,  especially  in  a  condition 
of  genu  valgum. 

In  the  rare  inward  dislocations  the  bone  lies  to  the  inner  side  of  the 
joint,  beyond  the  articular  surface  of  the  internal  condyle,  in  contact 
with  the  condyle  only  by  its  external  border;  or  if  rotation  exists, 
by  its  anterior  or  posterior  surface.  This  variety  also  is  usually  the 
result  of  direct  violence. 

In  the  dislocations'  by  rotation  of  the  patella  on  its  longitudinal  axis 
three  degrees  are  recognized:  first,  partial  rotation  with  lateral  dis- 
placement, when  the  outer  or  inner  edge  of  the  patella  lies  in  the 
intercondyloid  notch,  the  bone  resting  on  the  external  or  internal 
condyle,  the  so-called  incomplete  external  or  internal  dislocation; 
second,  when  the  rotation  is  through  a  larger  arc,  so  that  one  edge  of 
the  patella  rests  in  the  intercondyloid  notch  and  the  other  points 
vertically  upward,  the  so-called  edgewise  dislocation;  and  third,  when 
complete  rotation  has  taken  place,  the  anterior  surface  of  the  patella 
resting  upon  the  articular  surface  of  the  femur,  and  the  articular 
surface  of  the  patella  lying  immediately  underneath  the  skin. 

All  of  these  rotary  displacements  are  caused  by  direct  violence 
applied  to  the  outer  or  inner  edge  of  the  bone,  generally  during 
moderate  flexion  of  the  knee. 

Diagnosis. — This  is  generally  easy.  In  the  lateral  displacements 
the  joint  appears  widened,  with  an  irregular  projection  on  the  side  of 
the  displacement.  The  normal  prominence  of  the  patella  is  absent 
and  a  depression  exists  between  the  condyles.  The  bone  may  easily 
be  recognized  by  palpation  in  its  abnormal  position.  There  are  pain 
and  immobility  of  the  joint.  In  rotary  displacements  the  position 
of  the  bone  may  be  readily  made  out  by  inspection  and  palpation. 

Treatment. — In  all  of  these  dislocations  the  thigh  should  be  flexed 
on  the  body  and  the  knee  fully  extended  to  relax  the  quadriceps  exten- 
sor muscle.  When  this  is  accomplished,  reduction  may  easily  be  effected 
by  pressure  on  the  displaced  bone.  After  reduction  the  joint  should 
be  immobilized  for  a  week  or  more,  and  later  treated  by  massage  and 
hot  and  cold  douches  if  synovitis  exists.  Any  tendency  to  redisplace- 
ment  should  be  combated  by  a  knee-cap  or  elastic  bandage. 

Dislocations  of  the  Knee. — Dislocations  of  the  knee  are  rare,  and 
are  generally  the  result  of  severe  injury.  They  are  frequently  com- 
pound, and  often  are  accompanied  by  grave  complications.  They 
are  classified  according  to  the  direction  taken  by  the  displaced  tibia, 
and  in  the  order  of  frequency  are  forward,  backward,  outward,  inward, 
and  by  rotation. 


902  DISLOCATIONS 

Forward  dislocation  is  by  far  the  commonest.  It  may  be  complete 
or  incomplete,  and  is  frequently  compound.  It  is  caused  generally 
by  some  severe  force  resulting  in  hyperextension  of  the  leg,  or  by 
direct  violence  applied  just  above  and  in  front  of  the  knee  or  below 
and  behind.  When  complete,  the  popliteal  surface  at  the  back  of  the 
tibial  head  rests  upon  the  anterior  surface  of  the  condyles  of  the 
femur.  The  overriding  of  the  bones  may  amount  to  several  inches. 
The  ligaments  of  the  joint  are  extensively  torn;  the  popliteal  vessels 
and  nerves  are  tightly  stretched  over  the  condyles  of  the  femur  and 
may  lie  in  the  intercondyloid  notch.  More  or  less  injury  to  these 
structures  generally  results,  especially  to  the  artery,  which  may  be 
torn  or  later  may  become  occluded  by  rupture  of  its  internal  and 
middle  coats.  The  vein  is  less  frequently  injured.  When  compound, 
the  opening  is  usually  behind,  allowing  the  condyles  of  the  femur  to 
protrude. 

In  backward  dislocations,  when  complete,  the  anterior  border  of 
the  articular  surface  of  the  tibia  rests  upon  the  posterior  surface  of 
the  condyles  of  the  femur.  It  is  caused  by  direct  violence  above  or 
below  the  knee,  or  by  a  strong  forward  motion  of  the  body  while  the 
leg  is  fixed.  In  this  dislocation  the  ligaments  are  not,  as  a  rule,  so 
extensively  lacerated  as  in  the  forward  displacements.  The  patella 
may  be  fractured  or  displaced  laterally,  or  the  quadriceps  tendon  may 
be  torn.  The  popliteal  vessels  and  nerves  are  stretched  and  often 
injured,  as  in  the  forward  variety.  In  incomplete  forward  or  back- 
ward dislocations  the  articular  surfaces  are  not  entirely  separated, 
and  there  is  no  overriding. 

Lateral  dislocations  are  less  frequent,  and  may  be  complete  or 
incomplete.  The  complete  outward  or  inward  luxations  are  exceedingly 
rare;  the  articular  surfaces  are  entirely  separated;  the  head  of  the 
tibia  lies  to  the  outer  or  inner  side  of  the  femur,  producing  great 
deformity.  A  certain  amount  of  anteroposterior  displacement  may 
exist  with  rotation.  The  patella  and  its  tendon,  if  not  injured,  lie 
obliquely.  In  incomplete  lateral  displacements,  which  are  far  more 
common,  the  outer  tuberosity  of  the  tibia  rests  upon  the  inner  condyle, 
or  the  inner  tuberosity  upon  the  outer  condyle;  there  is  less  deformity, 
and  the  injury  to  surrounding  structures  is  less  extensive. 

In  rotary  dislocations  the  leg  is  violently  rotated  around  its  longi- 
tudinal axis,  the  ligamentous  structures  are  torn,  and  one  or  both 
condyles  are  displaced  forward  or  backward. 

Diagnosis.— The  recognition  of  these  dislocations  is  generally  easy, 
as  the  bones  are  so  superficial  that  any  change  in  their  relations  is 
readily  appreciated  by  inspection  and  palpation.  In  the  complete 
forms  the  deformity  is  great,  there  is  considerable  shortening,  and 
the  flat  articular  surface  of  the  tibia  is  easily  felt  in  its  abnormal 
position. 

In  the  complete  forward  variety  the  leg  is  extended,  the  antero- 
posterior diameter  of  the  joint  is  greatly  increased,  the  skin  above 


DISLOCATION  OF  THE  SEMILUNAR  CARTILAGES         903 

the  patella  is  relaxed  and  presents  one  or  more  transverse  folds, 
the  flattened  articular  surface  of  the  tibia  may  be  felt  in  front,  and 
the  rounded  condyles  of  the  femur  behind;  the  leg  is  numb  and 
cold  from  pressure  on  the  popliteal  nerves  and  vessels.  The  pulse 
in  the  posterior  tibial  and  dorsalis  pedis  vessels  may  be  absent.  In 
complete  backward  displacement  the  leg  is  hyperextended,  the  con- 
dyles of  the  femur  are  in  front  and  the  head  of  the  tibia  behind; 
pressure  symptoms  on  the  nerves  and  vessels  are  the  same.  In  com- 
plete lateral  displacement  the  deformity  is  so  characteristic  as  to  leave 
no  doubt  regarding  the  nature  of  the  injury.  In  incomplete  luxation 
and  rotary  displacement  there  is  no  shortening,  and,  as  a  rule,  no 
pressure  symptoms.  The  outlines  of  the  bones,  however,  can  be 
readily  made  out,  and  in  the  absence  of  swelling  the  diagnosis  is 
without  difficulty. 

Prognosis. — In  complete  dislocation  of  the  knee  the  prognosis  is 
grave  from  the  fact  that  from  20  to  25  per  cent,  of  the  cases  are 
compound,  and  also  from  the  fact  that  in  a  large  proportion  of  the 
forward  or  backward  displacements  the  popliteal  vessels  are  so  injured 
that  gangrene  of  the  leg  results.  In  other  instances  neuritis  develops, 
and  causes  grave  sensory,  motor,  and  trophic  disturbances.  In 
the  incomplete  varieties  the  prognosis  is  more  favorable,  but  more  or 
less  impairment  of  function  in  the  knee-joint  is  to  be  expected. 

Treatment. — In  all  varieties  of  this  injury  reduction  is  easily  accom- 
plished under  general  anesthesia  by  simple  traction  and  direct  pressure 
over  the  displaced  bone.  The  presence  or  absence  of  pulsation  in  the 
arteries  of  the  foot  should  be  noted  before  and  after  reduction.  Occa- 
sionally in  thrombosis  of  the  popliteal  artery  from  rupture  of  its  inner 
coats  collateral  circulation  will  be  established,  and  the  early  treatment 
therefore  should  be  expectant.  If  signs  of  gangrene  appear,  amputa- 
tion is  indicated.  When  the  circulation  is  unaffected  and  reduction 
is  accomplished,  the  leg  should  be  immobilized  for  several  weeks  to 
allow  repair  to  take  place  in  the  torn  ligaments;  and  if  considerable 
inflammatory  reaction  follows,  the  use  of  an  ice-bag  is  to  be  recom- 
mended. If  the  displacement  has  been  sufficient  to  rupture  the 
crucial  ligaments,  the  joint  should  be  opened  in  order  to  suture  these 
structures.  For  this  purpose  the  longitudinal  incision,  splitting  the 
patella,  gives  the  best  exposure.  This  should  only  be  done  after  at 
least  five  days  have  elapsed  since  the  accident  and  where  perfect 
technic  can  be  observed.  Passive  motion  should  be  undertaken  after 
the  second  week  and  a  knee-cap  worn  for  several  months. 

In  compound  dislocations  the  joint  should  be  freely  opened,  irri- 
gated, and  drained.  If  acute  general  sepsis  follows,  early  amputation 
will  be  necessary  to  save  life. 

Dislocation  of  the  Semilunar  Cartilages. — The  semilunar  cartilages 
of  the  knee-joint  are  occasionally  displaced  inward  or  outward  by 
some  slight  injury  or  unusual  motion  of  the  articulation.  The  inner 
meniscus  is  the  one  oftenest  affected,  and  the  displacement  is  gener- 


904  DISLOCATIONS 

ally  accompanied  by  a  bruising  or  a  partial  or  complete  rupture,  from 
its  being  caught  and  squeezed  between  the  condyle  of  the  femur  and 
articular  surface  of  the  tibia.  The  cause  of  the  displacement  is  gener- 
ally a  twisting  or  rotary  motion  of  the  body  while  the  feet  are  on  the 
ground  and  the  knee  partly  flexed  with  the  weight  on  the  opposite  leg, 
so  that  the  muscles  of  the  injured  side  are  relaxed.  It  frequently 
occurs  in  athletes,  especially  those  who  play  foot-ball,  tennis,  or  golf. 
The  symptoms  of  this  affection  are  generally  characteristic,  and 
resemble  those  caused  by  the  presence  of  a  floating  cartilage  in  the 
joint.  They  were  described  in  the  early  part  of  the  nineteenth  century 
by  Hey,  who  called  the  condition  an  "internal  derangement  of  the 
knee."  It  is  only  within  the  past  twenty  years  that  the  true  pathology 
of  the  affection  has  been  recognized. 

Diagnosis. — As  a  result  of  some  sudden  twisting  motion  of  the  leg, 
the  patient  immediately  experiences  a  severe  lancinating  pain  in  the 
knee,  with  "locking"  of  the  joint.  The  pain  is  often  so  severe  that 
the  patient  falls  to  the  ground  and  is  unable  to  execute  any  voluntary 
movement  of  the  limb.  The  symptoms  may  persist  for  some  time 
and  gradually  disappear,  or  as  a  result"  of  forcibly  flexing  and  extend- 
ing the  leg  all  pain  may  suddenly  be  relieved  and  the  functions  of  the 
joint  completely  restored.  There  is,  however,  a  strong  tendency  to 
recurrence,  and  patients  are  often  more  or  less  disabled  by  these 
frequently  recurring  attacks.  Not  infrequently  a  certain  amount 
of  effusion  appears  in  the  joint  after  such  an  attack,  requiring  rest  in 
bed  and  the  application  of  an  ice-bag.  Examination  of  the  joint  may 
be  negative,  or,  in  the  rare  outward  displacements  of  the  meniscus  a 
projection  may  be  felt  between  the  articular  surfaces  of  the  tibia 
and  femur. 

Treatment. — For  the  acute  attack  prompt  flexion  and  extension  of 
the  leg  will  often  give  immediate  relief.  The  pain  of  this  maneuvre 
however,  is  often  severe  and  an  anesthetic  is  frequently  desirable. 
If  tenderness  and  an  effusion  into  the  joint  follow  the  attack,  the 
patient  should  be  kept  in  bed,  the  joint  immobilized,  and  an  ice- 
bag  applied  for  several  days.  To  prevent  recurrences  the  patient 
should  avoid  weight-bearing  until  the  fluid  has  disappeared  from  the 
joint  and  the  muscles  of  the  thigh  have  regained  their  tone  suffi- 
ciently to  hold  the  knee  in  a  stable  condition.  The  laxity  of  the 
muscles  is  a  strong  predisposing  factor  in  the  recurrence  of  the  locking. 
The  use  of  a  steel  brace  has  been  recommended,  which  prevents 
rotation  and  allows  only  a  limited  amount  of  flexion  and  extension 
at  the  knee.  Not  infrequently,  after  a  large  number  of  such  attacks 
complete  relief  will  follow  the  giving  up  of  athletics  in  general  or  the 
particular  sport  which  seemed  to  occasion  the  symptoms.  In  many 
cases,  however,  the  attacks  continue  in  spite  of  the  greatest  care,  and 
in  these  open  operation  is  to  be  recommended. 

The  operation  is  best  performed  with  the  knee  flexed,  the  leg  hanging 


DISLOCATIONS  OF  THE  ANKLE  905 

over  the  edge  of  the  operating  table.  An  incision  is  made  along  the  inner 
border  of  the  patella  to  a  point  opposite  the  joint  line,  then  curved 
backward  for  about  two  inches.  The  capsule  is  divided  and  the  joint 
cavity  opened.  By  retracting  the  patella  and  its  ligament  outward,  the 
articular  surface  of  the  tibia  is  well  exposed  and  the  internal  meniscus 
easily  examined.  If  found  to  be  displaced  but  uninjured,  it  may 
be  sutured  in  place.  If  ruptured,  or  completely  dislocated  inward 
so  that  it  lies  in  the  intercondyloid  space,  it  should  be  removed  by 
severing  its  anterior  and  posterior  attachments.  The  joint  cavity  is 
then  irrigated  with  normal  salt  solution  to  remove  any  blood  clots, 
and  the  wound  closed  with  a  running  suture  of  catgut  for  the  capsule, 
and  two  or  three  interrupted  silkworm-gut  sutures  for  the  skin. 
After  applying  a  sterile  gauze  dressing  the  limb  is  extended  and 
placed  in  a  long  posterior,  splint.  As  soon  as  the  wound  is  healed, 
passive  motion  and  massage  should  be  employed. 

Dislocations  of  the  Fibula. — The  upper  extremity  of  the  fibula  may 
be  dislocated  backward,  forward,  or  upward.  These  displacements 
may  be  caused  by  direct  violence,  indirect  violence,  by  an  injury  to 
the  ankle  and  upward  pressure  on  the  fibula,  and  by  violent  contrac- 
tion of  the  biceps  muscle,  the  latter  producing  generally  the  backward 
luxation. 

The  lower  extremity  of  the  fibula  has  been  displaced  backward  with- 
out fracture  in  a  few  recorded  cases. 

All  of  these  varieties  are  rare,  and  are  easily  recognized.  They  are 
generally  reduced  by  direct  pressure,  aided  by  flexion  of  the  knee 
to  relax  the  biceps,  in  those  at  the  upper  end;  and  by  e version  or 
inversion  of  the  foot  in  those  occurring  at  the  inferior  extremity. 

Dislocations  of  the  Ankle. — Dislocations  of  the  ankle  are  fairly  fre- 
quent, and  a  large  number  of  varieties  have  been  described.  The 
separation  may  take  place  at  the  tibiotarsal  articulation,  where  the 
foot  with  the  astragalus  may  be  displaced  backward,  forward,  out- 
ward, inward,  or  upward;  at  the  astragalocalcaneoid  and  astragalo- 
scaphoid  joints,  the  subastragaloid  dislocation,  when  the  direction  of 
displacement  of  the  foot  may  be  backward,  forward,  outward  or 
inward;  at  both  of  these  joints,  resulting  in  a  displacement  of  the 
astragalus  alone,  which  may  be  forward,  backward,  inward,  outward, 
or  its  position  simply  changed  by  rotation. 

Tibiotarsal  Dislocations. — These  are  generally  produced  by  falls 
upon  the  foot  in  the  position  of  dorsal  or  plantar  flexion,  or  by  strong 
abduction  or  adduction  of  the  foot,  the  former  resulting  in  antero- 
posterior displacements,  the  latter  in  lateral  luxations.  In  the  antero- 
posterior displacements  the  foot  with  the  astragalus  may  be  displaced 
backward  or  forward.    The  backward  dislocation  is  the  commonest. 

Symptoms. — In  backward  dislocations  the  foot  is  shortened,  the 
heel  is  prominent,  and  the  tendo  Achillis  tense;  the  malleoli  project 
anteriorly  and  their  relations  with  the  tarsus  are  altered.    In  forward 


906  DISLOCATIONS 

dislocations  the  foot  is  lengthened,  the  heel  and  tendo  Aehillis  are 
less  prominent,  and  the  space  on  either  side  of  the  tendon  is  occupied 
by  displaced  tibia  and  fibula.  The  malleoli  are  nearer  the  heel  and 
lower  than  normal;  the  articular  surface  of  the  astragalus  can  be  felt 
in  front  of  the  tibia.  Incomplete  backward  or  forward  dislocations 
may  occur,  the  symptoms  of  which  are  the  same  but  less  marked. 

The  lateral  dislocations  are  almost  always  accompanied  by  fracture. 
In  the  outward  variety  the  accompanying  fracture  is  of  the  fibula, 
and  has  already  been  described  as  Pott's  fracture.  In  this  the  dis- 
location is  incomplete,  and  consists  in  rotation  outward  of  the  tarsus 
without  displacement  of  the  astragalus  beyond  the  malleolus.  In 
the  incomplete  inward  variety  the  inner  malleolus  or  lower  part  of 
the  tibia  is  fractured;  the  rotation  of  the  tarsus  is  inward.  Complete 
dislocations  outward  or  inward  when  the  astragalus  is  displaced 
wholly  without  the  tibiofibular  mortice  are  exceedingly  rare.  In 
these  the  limb  is  shortened,  the  ankle  is  greatly  increased  in  breadth, 
and  the  foot  is  in  extreme  outward  or  inward  rotation.  Upward 
dislocation  is  exceedingly  rare.  It  is  caused  by  a  fall  from  a  height  on 
the  feet.  The  inferior  tibiofibular  articulation  is  separated  and  the 
astragalus  is  driven  upward  between  these  bones.  The  joint  is  widened ; 
the  malleoli  approach  the  sole  of  the  foot.  It  is  generally  accompanied 
by  fracture. 

Treatment. — In  all  of  these  dislocations  reduction  is  easily  accom- 
plished. In  anteroposterior  displacements  the  knee  should  be  flexed 
to  relax  the  tendo  Aehillis.  The  foot  should  then  be  grasped  by  the 
surgeon  and  firm  traction  made  while  the  knee  is  held  by  an  assistant. 
This,  with  pressure  forward  or  backward  on  the  lower  extremity  of 
the  leg  and  a  slight  rocking  motion  of  the  foot,  will  generally  succeed. 
In  lateral  displacements  the  reduction  of  the  fracture  as  well  as  the 
dislocation  must  be  made,  and  in  the  outward  variety  the  foot  should 
be  held  in  an  inverted  position  by  a  Dupuytren  splint  or  plaster-of- 
Paris  cast.  In  dislocations  without  fracture  the  joint  should  be 
immobilized  for  ten  days,  after  which  massage  and  passive  motion 
should  be  employed. 

Subastragaloid  Dislocations. — In  these  luxations  the  astragalus 
remains  with  the  tibia  and  fibula.  The  separation  takes  place  between 
the  astragalus  and  the  scaphoid  and  os  calcis.  The  displacement  of 
the  foot  is  generally  obliquely  backward  and  inward  or  backward  and 
outward.  Dislocations  directly  backward,  or  forward,  or  laterally, 
are  extremely  rare.  These  injuries  are  caused  generally  by  severe 
twists  of  the  ankle.  They  are  not  infrequently  accompanied  by  frac- 
tures of  the  malleoli. 

Diagnosis. — The  diagnosis  is  not  always  easy  in  the  presence  of 
extensive  swelling.  In  backward  and  inward  displacements  the  dor- 
sum of  the  foot  appears  shortened,  the  heel  is  lengthened,  there  are 
inversion  of  the  foot  and  a  prominence  externally  and  in  front,  caused 


DISLOCATIONS  OF  TARSAL   BQNES  90' 

by  the  displaced  astragalus  and  external  malleolus.  In  backward 
and  outward  displacements  the  foot  is  everted  and  the  astragalus  and 
internal  malleolus  form  a  prominence  internally  and  in  front.  The 
relation  between  the  head  of  the  astragalus  and  the  malleoli  is  normal. 
There  is  preservation  of  the  anteroposterior  movements  in  the  tibio- 
tarsal  joint,  but  the  lateral  and  rotary  movements  of  the  ankle  are  lost 
or  painful. 

Treatment. — Reduction  is  not  always  easy,  owing  in  certain  cases 
to  engagement  of  the  head  of  the  astragalus  under  the  tendon  of  the 
tibialis  anticus  muscle  in  the  backward  and  outward  variety,  and 
occasionally  to  fracture  of  the  astragalus  in  the  others.  Reduction 
should  be  attempted  in  all  cases  by  flexing  the  knee  to  relax  the  tendo 
Achillis,  and  by  downward  and  forward  traction  on  the  foot,  with 
direct  pressure  backward,  on  the  lower  extremity  of  the  tibia. 

Dislocations  of  the  Astragalus. — The  astragalus  may  be  forced  from 
its  bed  and  displaced  in  almost  any  direction.  The  cause  is  generally 
a  fall  upon  the  foot  from  a  height,  or  any  severe  twisting  injury  to  the 
ankle.  The  most  frequent  direction  of  the  displacement  is  forward 
and  outward  or  forward  and  inward;  occasionally  the  bone  is  rotated 
without  being  forced  out  of  its  bed.  In  the  forward  and  outward 
variety  the  foot  is  inverted,  and  the  bone  can  easily  be  felt  lying  in 
front  of  the  tibia,  resting  upon  the  outer  tarsal  bones.  In  the  forward 
and  inward  variety  the  foot  is  everted  and  the  bone  can  be  seen  and 
felt  just  in  front  of  the  internal  malleolus.  In  the  rotary  displacements 
little  or  no  deformity  may  be  present,  but  motion  is  much  restricted 
and  painful. 

Treatment. — The  treatment  should  consist,  first,  in  attempting 
reduction  under  anesthesia  by  traction  and  direct  pressure  over  the 
bone,  the  knee  being  held  in  a  flexed  position  by  an  assistant,  who 
also  exercises  strong  counter-extension.  If  this  fails,  open  incision  and 
replacement  or  excision  of  the  bone  should  be  practised. 

Mediotarsal  Dislocations. — In  this  dislocation,  which  is  exceedingly 
rare,  the  cuboid  and  scaphoid  are  separated  from  the  astragalus  and 
os  calcis.  The  displacement  is  generally  downward.  In  the  complete 
dislocation  the  foot  is  shortened,  the  arch  obliterated  by  the  depressed 
cuboid  and  scaphoid,  and  there  is  a  prominence  on  the  dorsum  made 
by  the  head  of  the  astragalus  and  the  cuboid  surface  of  the  os  calcis. 
This  dislocation  may  be  accompanied  by  fracture  of  one  of  the  bones 
or  of  the  external  malleolus. 

Dislocations  of  the  Other  Bones  of  the  Tarsus. — These  may  occur 
separately  or  in  various  combinations.  Those  of  the  cuneiform  bones 
are  commonest,  and  of  these  the  first  is  more  often  displaced  singly 
than  the  others. 

Dislocation  of  the  metatarsal  bones  may  occur  singly  or  in  combina- 
tion. The  entire  metatarsus  has  been  displaced  from  the  tarsus  in  a 
number  of  cases.  These  luxations  are  generally  upward,  but  may 
occur  downward,  and  in  case  of  the  entire  metatarsus,  laterally.    The 


908  DISLOCATIONS 

first  metatarsal  bone  is  most  frequently  dislocated  singly,  and  the 
direction  of  the  displacement  is  generally  upward  on  the  dorsum. 

Dislocations  of  the  'phalanges  are  rare,  the  commonest  being  at  the 
metatarsophalangeal  joint  of  the  great  toe.  Dislocations  at  the 
metatarsophalangeal  joints  of  the  other  toes  and  of  the  terminal 
phalanx  of  the  great  toe  have  been  reported,  but  are  exceedingly  rare. 

In  all  of  these  dislocations  the  diagnosis  is  made  without  difficulty 
in  the  absence  of  great  swelling.  When  this  is  present,  an  a-ray 
examination  will  serve  to  establish  it. 

Treatment. — The  treatment  should  consist  in  traction  and  direct 
pressure  over  the  displaced  bone. 


CHAPTER  XXXI. 
HERNIA. 

The  term  Hernia  is  used  to  signify  the  protrusion  of  an  organ 
from  the  cavity  in  which  it  is  normally  contained,  as  hernia  cerebri, 
following  trauma.  When  this  term  is  unqualified,  it  is  understood  as 
denoting  a  protrusion  from  the  abdominal  cavity,  through  a  weakened 
portion  of  the  wall,  .and  implies  a  pouching  of  the  containing  wall 
forming  a  continuous  covering  for  the  displaced  contents. 

To  facilitate  the  discussion  of  this  condition,  it  will  be  profitable 
to  review  very  briefly  certain  transitory  conditions,  which  exist  during 
embryonic  life,  and  the  structure  of  the  containing  walls  of  the 
abdominal  cavity,  as  they  exist  in  the  adult. 

Embryology. — Until  the  end  of  the  eighth  week  of  fetal  life,  the 
testicles  and  ovaries  have  occupied  a  position  well  forward  in  the 
abdominal  cavity,  and  at  the  beginning  of  the  third  month,  lie  opposite 
the  lumbar  vertibrce.  From  this  time  until  birth,  they  gradually 
move  toward  the  position  which  they  will  occupy  in  the  adult. 

In  the  latter  part  of  the  second,  or  beginning  of  the  third  month  of 
fetal  life,  at  the  point  where  the  gubernaculum  pierces  the  body  wall, 
there  is  an  evagination  of  the  peritoneum,  knowm  as  the  processus 
vaginalis  peritonei.  The  evagination  is  for  a  time  a  shallow  depression, 
but  gradually  increases  in  size  and  accompanies  the  gubernaculum  to 
its  lower  point  of  attachment.  During  the  ninth  month,  in  the  male, 
the  testicle  descends  beside  the  processus  vaginalis,  through  the 
inguinal  canal,  and  comes  to  lie  in  the  scrotum.  Normally  the  pro- 
cessus vaginalis  becomes  shut  off  just  above  the  testicle  and  forms  a 
partial  serous  investment  for  that  organ,  known  as  the  tunica  vaginalis, 
and  that  portion  of  the  processus  vaginalis  lying  between  the  internal 
ring  and  the  tunica  vaginalis  becomes  completely  obliterated. 

Deviations  from  the  normal  occur  (Moschowitz) .     Among  them  are : 

1.  The  processus  vaginalis  may  remain  open  in  its  entire  extent. 

2.  The  processus  vaginalis  may  close  off  at  its  lower  end,  forming  a 
complete  tunica  vaginalis  for  the  testis,  but  it  remains  patent  at  the 
internal  ring. 

3.  The  processus  vaginalis  may  remain  open  at  its  lower  end  but 
becomes  shut  off  at  its  upper  end. 

4.  The  processus  vaginalis  may  form  the  tunica  vaginalis  as  is  normal, 
and  may  also  become  shut  off  at  the  internal  ring,  but  the  intervening 
portion  does  not  become  obliterated. 

5.  The  processus  vaginal  may  form  the  normal  tunica  vaginalis,  and 
the  upper  part  becomes  shut  off  at  or  in  the  neighborhood  of  the 


910  HERS  I A 

external  inguinal  ring,  while  the  most  superior  portion  remains  patent 
and  communicates  with  the  general  peritoneal  cavity. 

6.  The  processus  vaginalis  may  begin  the  shutting  off  of  the  normal 
tunica  vaginalis,  but  the  process  may  stop  before  it  is  entirely  com- 
pleted. In  other  words,  the  sac  may  not  improperly  be  compared 
to  an  hour-glass  open  at  its  top,  the  size  of  the  two  halves 
varying. 

If  the  processus  vaginalis  remains  patent  in  the  female  it  is  known  as 
the  canal  of  Xuck. 

Incomplete  obliterations  of  the  processus  vaginalis  may  give  rise  to 
cystic  swellings,  known  as  hydroceles  of  the  cord  or  round  ligament. 

Anatomy. — For  detailed  anatomy,  the  reader  is  referred  to  special 
works  upon  the  subject.  There  are  a  few  structures,  however,  with 
the  relationship  of  which  it  is  necessary  to  be  familiar  to  understand 
the  morbid  anatomy  of  the  subject  under  consideration. 

The  two  structures  which  do  most  to  protect  the  potential  weakness 
which  exists  in  the  inguinal  region  are  the  internal  oblique  muscle 
and  the  transversalis  fascia.  In  a  well-developed  subject  the  lower 
part  of  the  internal  oblique  muscle  consists  of  a  thick  mass  of  fibres 
which  arise  from  the  outer  half  of  Poupart's  ligament,  and  pass 
horizontally  to  their  insertion  in  front  of  the  rectus. 

The  question  as  to  whether  a  person  will  develop  a  hernia  in  this 
region  depends  largely  upon  the  development  of  this  muscle  and  it- 
relation  to  other  structures,  especially  Poupart's  ligament. 

Blake  has  called  attention  to  the  fact  that  "  if  Poupart's  ligament 
takes  a  horizontal  direction  as  in  the  female,  the  internal  oblique 
coincides  with  it  and  there  is  consequently  a  strong  inguinal  region, 
but  if,  as  in  some  males  with  deep  and  narrow  pelves,  Poupart's  liga- 
ment takes  a  more  oblique  course,  there  is  an  unprotected  triangular 
space,  bounded  cephalad  by  the  internal  oblique,  mesad,  by  the 
margin  in  the  rectus,  and  caudad,  by  Poupart's  ligament,  which  may 
be  called  the  undefended  space,  and  through  which  hernia  is  apt  to 
occur,  especially  the  direct  variety,  when  the  structures  become 
relaxed  by  age." 

In  the  inguinal  region,  the  transversalis  fascia  in  the  region  of  the 
internal  ring  is  made  up  of  strong  fibres,  curving  in  a  sling-like  manner 
about  the  inner  and  lower  border  of  the  ring,  the  so-called  inguinal 
ligaments  of  Henle.  Just  across  the  inner  side  of  the  deep  epigastric 
artery,  at  the  usual  site  of  a  direct  inguinal  hernia,  is  a  weaker  portion 
of  this  fascia,  which  further  toward  the  midline  is  made  up  of  strong 
vertical  fibres. 

Neither  the  transversalis  muscle  nor  the  conjoined  tendons  are 
important  factors  in  preventing  the  occurrence  of,  or  in  repairing  an 
exi-ting,  hernia. 

Nerves. — As  it  is  frequently  desirable  to  operate  upon  inguinal  or 
femoral  hernia  under  local  anesthesia  alone  or  in  combination  with 
nitrous  oxide  and  oxygen,  an  accurate  knowledge  of  location  of  the 


THE  SPERMATIC  CORD  911 

nerves  supplying  this  region  is  essential.     Braun  has  described  the 
innervation  of  this  region  as  follows: 

"The  external  spermatic  nerve,  which  is  a  branch  of  the  genitocrural, 
joins  the  spermatic  cord  at  the  internal  ring,  and  accompanying  it, 
emerges  from  the  inguinal  canal  on  the  under  surface  of  the  cord. 

"The  ilio-inguinal  nerve  lies  above  the  spine  of  the  ilium,  between  the 
oblique  abdominal  muscles,  passing  under  the  fascia  of  the  external 
oblique,  it  leaves  the  inguinal  canal  on  the  anterior  surface  of  the 
hernial  sac  or  the  spermatic  cord. 

"The  iliohypogastric  runs  almost  parallel  with  and  a  little  higher 
than  the  former,  between  the  oblique  abdominal  muscles,  and  in  the 
inguinal  region  under  the  aponeurosis  of  the  external  oblique  muscle.  It 
penetrates  the  anterior  sheath  of  the  rectus,  in  this  manner  reaching 
the  subcutaneous  tissues,  innervating  the  skin  of  the  inguinal  region." 

As  these  three  nerves  form  a  plexus  in  their  ultimate  distribution, 
one  or  even  two  of  the  main  trunks  may  be  absent — all  of  the  fibres 
being  carried  by  the  remaining  nerve. 

Cushing  has  called  attention  to  the  fact  that  if  the  three  nerves  first 
mentioned  are  blocked  at  their  entrance  into  the  inguinal  canal,  the 
greater  part  of  the  field  will  become  insensitive. 

Bloodvessels. — The  course  of  the  deep  epigastric  artery  may  be 
indicated  on  the  surface  of  the  body  by  a  line  drawn  from  the  middle 
of  Poupart's  ligament  toward  the  umbilicus.  Shortly  after  this  line 
crosses  the  linea  semilunaris  the  direction  changes  and  the  vessel  is 
directed  cephalad  in  the  line  of  junction  of  the  inner  third  with  the 
outer  two-thirds  of  the  rectus  muscle. 

This  vessel  arises  just  above  Poupart's  ligament  from  the  external 
iliac;  as  it  curves  forward  it  lies  in  the  extraperitoneal  fat,  turns 
around  the  lower  border  of  the  peritoneal  sac,  and  runs  upward  and 
inward  along  the  inner  side  of  the  internal  abdominal  ring,  and  along 
the  outer  border  of  Hesselbach's  triangle. 

Obturator  Artery. — In  about  30  per  cent,  of  the  cases  the  obturator 
artery  instead  of  arising  from  the  internal  iliac  is  given  off  from  the 
deep  epigastric  artery,  in  which  case  it  must  descend  nearly  vertically 
to  enter  the  upper  part  of  the  obturator  foramen.  In  its  descent  to 
this  foramen  it  usually  passes  downward  on  the  lateral  aspect  of  the 
crural  canal  in  contact  with  the  external  iliac  vein.  However,  in 
3  per  cent,  of  all  cases,  it  passes  downward  along  the  free  edge  of  Gim- 
bernat's  ligament,  and  thus  almost  completely  encircles  the  neck  of  an 
existing  femoral  hernial  sac,  and  might  be  subject  to  injury  in  division 
of  the  structures  about  its  neck. 

The  Spermatic  Cord.— The  spermatic  cord  is  composed  of  the  vas 
deferens,  the  artery  of  the  vas,  the  veins  of  the  vas,  the  spermatic 
artery  and  spermatic  veins  proper,  the  sympathetic  nerves  and  the 
lymphatics;  these  are  all  surrounded  by  the  infundibuliform  fascia, 
the  cremasteric  fascia  and  muscle,  and  the  intercolumnar  fascia. 
The  spermatic  artery  is  a  branch  of  the  aorta,  and  the  artery  of  the 


912  HERNIA 

vas  is  a  branch  from  the  superior  or  middle  vesical  artery.  Either  one 
can  be  ligated  without  interfering  with  the  function  of  the  testicle 
(Bevan). 

The  veins  may  be  divided  into  two  groups:  an  anterior  and  a  poste- 
rior, the  former  accompanying  the  spermatic  artery  and  emptying, 
those  on  the  right  side  into  the  ascending  vena  cava,  on  the  left,  into 
the  renal  vein. 

The  posterior  group  accompanying  the  artery  of  the  vas  empties 
largely  into  the  deep  epigastric  veins. 

The  vas  deferens  can  be  readily  distinguished  from  the  other 
structures  in  the  cord  by  its  hard,  firm  consistence. 

Etiology. — Two  factors  are  always  present  in  a  given  case  of  hernia, 
a  weakening  of  the  abdominal  wall,  which  predisposes  the  individ- 
ual to  the  disease,  and  the  occurrence  of  increased  intra-abdominal 
pressure,  which  acts  as  the  exciting  cause. 

Coley  states  that  in  the  vast  majority  of  cases  hernia  is  due  to  a 
congenital  defect  or  an  abnormal  size  of  some  normal  opening  in  the 
abdominal  wall.  He  considers  the  congenital  defect  the  main  cause, 
while  the  exciting  cause  plays  a  minor  role. 

R.  Hamilton  Russell,  who  has  studied  at  great  length  the  embryology 
of  this  condition,  goes  so  far  as  to  say  that  oblique  inguinal  hernia  is 
invariably  caused  by  the  presence  of  a  congenital  sac,  which  is  produced 
by  the  patency  of  the  whole  or  a  part  of  the  processus  vaginalis. 

That  even  a  direct  hernia  may  have  a  preformed  sac  was  demon- 
strated by  Russell,  who  has  a  specimen  of  a  direct  inguinal  sac,  asso- 
ciated with  an  open  funicular  process  in  the  same  side,  which  was 
taken  from  a  man  who  had  never  been  the  subject  of  hernia.  In 
femoral  hernia  there  may  be  an  abnormally  large  femoral  ring,  but 
here,  too,  Russell  believes  that  there  may  be  a  congenital  preformed 
sac; 

Incomplete  union  of  the  structures  about  the  umbilicus  is  a 
predisposing  cause  of  hernias  in  this  region. 

Other  predisposing  causes  which  should  be  mentioned  are:  Heredity, 
age,  sex,  pregnancy,  obesity,  atrophic  changes,  and  trauma. 

Heredity. — McCraedy  states  that  25  per  cent,  of  the  patients  with 
hernia  give  a  family  history  of  this  condition. 

Age. — The  majority  of  patients  are  between  the  age  of  twenty-one 
and  fifty. 

Sex. — The  relative  frequency  has  been  variously  estimated  by  differ- 
ent authors  as  occurring  between  75  to  84  per  cent,  in  males,  25  to 
16  per  cent,  in  females.  The  predominance  of  males  has  been  ex- 
plained on  the  basis  of  the  greater  frequency  of  inguinal  hernia  in  the 
male,  and  by  the  role  played  by  occupation  as  an  exciting  cause. 

Pregnancy. — The  stretching  and  the  subsequent  relaxation  of  the 
abdominal  wall,  due  to  pregnancy,  ascites,  or  obesity  is  a  predisposing 
cause  of  hernia,  especially  the  umbilical  type,  and  that  associated 
with  a  diastasis  of  the  recti. 


CLINICAL  CLASSIFICATIONS  913 

Atrophic  Changes. — Atrophic  changes  as  occur  with  senility  or  with 
wasting  constitutional  diseases. 

Trauma. — There  may  be  a  formation  of  cicatricial  tissue,  following 
local  injury  or  surgical  operations;  or  nerve  lesions  caused  by  trauma, 
resulting  in  the  atrophy  of  muscles  they  innervated. 

Exciting  Causes. — Any  condition  which  produces  increased  intra- 
abdominal pressure  may  act  as  an  exciting  cause.  Thus,  occupations 
necessitating  heavy  lifting  or  straining  are  factors;  also  coughing, 
parturition,  obstruction  to  urination,  constipation,  abdominal  tumors 
or  ascites. 

The  constituent  parts  of  a  hernia  are  the  sac,  contents  and  cov- 
erings. 

The  sac  consists  ol  peritoneum,  its  shape  depends  upon  the  shape  of 
the  opening,  through  which  it  penetrates  the  abdominal  wall,  and  the 
degree  of  restraint  offered  by  the  overlying  tissues:  thus  an  umbilical 
hernia  is  apt  to  be  globular;  an  inguinal  hernia  which  has  not  descended 
beyond  the  external  ring  sausage-shape;  while  one  that  has  descended 
into  the  scrotum  may  be  pyriform.  Sacculations  may  exist  in  the 
sac  wall,  or  be  due  to  constrictions  of  overlying  bands  of  tissue. 
According  to  Russell,  "All  of  the  multitudinous  varieties  of  inguinal 
hernia  owe  their  origin  to  the  corresponding  varieties  of  sacculation  of 
the  sac." 

Not  infrequently  some  of  these  sacculations  become  encysted 
(hydrocele  of  the  sac). 

The  contents  vary.  Almost  every  abdominal  organ  has  at  some  time 
been  noted  as  present  in  a  hernial  sac.  The  most  frequently  noted 
contents  are  omentum,  and  intestine.  A  hernia  containing  omentum 
alone  is  called  an  epiplocele,  one  containing  intestine  alone,  an  enterc- 
cele,  while  one  containing  both  is  termed  an  entero-epiplocele.  The 
coverings  of  a  hernia  vary  with  the  site,  and  usually  consist  of  fascia 
and  skin. 

Clinical  Classifications. — Clinically,  hernias  are  designated  as  redu- 
cible, irreducible,  inflamed,  obstructed,  and  strangulated. 

A  reducible  hernia  is  one  in  which  the  entire  contents  of  the  sac  can 
be  reduced  into  the  abdominal  cavity  without  a  cutting  operation. 

An  irreducible  hernia  is  one  in  which  the  contents  of  the  sac  cannot 
be  completely  reduced  into  the  abdominal  cavity  without  a  cutting 
operation. 

The  cause  of  the  irreducibility  may  be: 

1.  Adhesions  between  the  contents  (usually  omentum)  and  the  sac 
wall. 

2.  Adhesions  between  the  contents  of  the  sac,  as  between  intestine 
and  omentum. 

3.  Bulk  of  sac  contents  (too  great  to  be  returned  to  the  abdominal 
cavity). 

4.  Increase  in  the  size  of  the  sac  contents  (thickened  edematous 
omentum). 

58 


014  HERNIA 

5.  Sliding  hernias — where  part  of  the  sac  is  formed  by  the  wall  of 
the  gut. 

An  inflamed  hernia  is  one  in  which  a  local  peritonitis  exists  in  the 
sac.  It  is  frequently  produced  by  prolonged  taxis,  or  an  ill-fitting 
truss,  but  may  be  caused  by  enteritis  or  obstruction. 

An  incarcerated  or  obstructed  hernia  is  one  in  which  there  is  interfer- 
ence with  the  passage  of  the  bowel  contents  but  without  interference 
with  the  circulation.  The  obstruction  is  not  necessarily  complete, 
as  gas  is  frequently  passed.  It  is  most  common  in  hernia  containing 
large  intestine. 

A  strangulated  hernia  is  one  in  which  there  has  been  both  an  interfer- 
ence with  the  blood  supply  of  the  intestine  and  with  the  passage  of 
bowel  contents. 

The  mechanism  of  strangulations  has  been  the  subject  of  investiga- 
tion since  the  condition  was  first  recognized,  and  many  conflicting 
hypotheses  have  been  advanced  as  to  its  causation.  The  term 
"elastic  strangulation"  has  been  given  by  the  Germans  to  a  mechan- 
ism of  strangulation,  first  suggested  by  Wilmes  as  early  as  1788,  and 
subsequently  amplified  by  Manchart.  According  to  this  theory, 
when  a  loop  of  bowel  is  forced  through  a  narrow  hernial  aperture  or 
when  more  bowel  is  driven  down  into  a  hernia  already  protruding, 
there  is  a  disproportion  between  the  protruding  parts  and  the  ring. 
The  opening  during  the  passage  of  the  gut  is  dilated  to  its  utmost, 
it  then  recoils  and  compresses  the  intestine,  thus  producing  a  strangu- 
lation. "All  subsequent  theories  of  strangulation  which  have  been 
put  forward  to  supplement  or  to  supplant  that  of  elastic  strangulation, 
have  been  chiefly  of  academic  interest  and  affect  in  no  way  the  rules 
of  treatment.  Most  of  them  rest  upon  the  assumption  that  the 
pressure  within  the  bowel  above  the  sac,  or  in  the  sac,  may  be  suddenly 
raised  by  a  down-rush  of  intestinal  contents,  and  this  rise  of  pressure 
in  one  way  or  another  causes  obstruction"  (Macready). 

Morbid  Anatomy. — When  interference  with  the  circulation  of  a 
hernia  takes  place,  it  usually  comes  about  gradually.  In  exceptional 
cases  the  disproportion  between  the  hernal  aperture  and  the  protru- 
sion may  be  so  great  that  the  arterial  and  venous  streams  are  both 
immediately  stopped. 

Most  commonly  the  venous  circulation  is  the  first  to  be  retarded, 
and  is  manifest  by  the  dark  red  or  bluish  and  edematous  appearance 
of  the  gut  wall  and  the  transudation  of  clear  serum  into  the  sac. 

Gare  has  pointed  out  the  fact  that  the  fluid  in  the  sac  of  a  non- 
strangulated  hernia  is  absolutely  sterile. 

There  are  two  conditions  under  which  one  may  not  be  able  to 
demonstrate  fluid  in  the  sac  of  a  strangulated  hernia :  First,  there  may 
be  a  complete  absence  of  fluid,  due  to  a  complete  and  immediate 
stopping  of  venous  and  arterial  circulation.  Second,  due  to  adhesions 
between  the  viscera  and  the  front  of  the  sac;  the  fluid  may  be  collected 
at  the  back  of  the  sac  (Macready). 


MORBID  ANATOMY  915 

If  the  interference  with  the  circulation  is  continued  the  color  of  the 
gut  becomes  purple  and  later  gray  or  black.  The  peritoneal  covering 
loses  its  lustre  and  becomes  granular  in  appearance,  but  in  this  connec- 
tion it  must  be  remembered  that  the  lustre  of  the  serous  coat  may  be 
dimmed  by  an  inflammatory  process,  though  the  loop  is  still  viable. 

For  a  time  it  may  be  possible  to  demonstrate  the  pulsation  of 
mesenteric  vessels  supplying  the  protruding  loop  or  when  the  bowel  is 
stroked,  the  vessels  may  be  emptied  and  seen  to  refill,  or  if  still  living, 
the  gut  wall  will  bleed  if  pricked;  but  as  gangrene  supervenes,  these 
signs  are  lost.  There  is  frequently  a  thrombosis  of  the  mesenteric 
vessels  of  sufficient  extent  to  compromise  the  circulation  of  segments 
of  intestine  within  the  abdominal  cavity. 

The  fluid  in  the  sac  which  at  first  was  clear  and  odorless,  may 
successively  become  reddish  brown,  dark  brown,  or  coffee-ground 
color,  and  take  on  a  foul  odor.  The  foul  odor  is  not  in  itself  to  be 
taken  as  a  sign  of  gangrene.  In  late  stages  the  fluid  is  found  to  contain 
various  pathogenic  organisms,  which  have  found  their  way  through 
the  damaged  gut  walls. 

The  intestinal  wall  loses  its  power  of  contractility,  is  of  lower 
temperature  than  the  surrounding  tissues  and  frequently  becomes 
distended  with  gas  and  fluid.  Its  surface  may  be  covered  with  fibrin. 
Where  great  or  prolonged  pressure  has  been  exerted  at  the  point  of 
stricture,  the  various  coats  of  the  intestine  become  necrosed  and  give 
way.  Micaise  has  called  attention  to  the  fact  that  they  give  way 
in  the  following  order:  (1)  The  mucous  membrane,  (2)  circular  mus- 
cular fibres,  (3)  longitudinal  muscular  fibres,  (4)  the  strong  connective 
layers  of  the  intestine,  (5)  the  serosa. 

If  this  condition  is  not  relieved  by  operative  interference  it  may 
terminate  in  any  one  of  several  ways.  The  strangulated  loop  may 
rupture  into  the  hernial  sac,  or  a  local  peritonitis  exist  in  the  sac, 
due  to  the  migration  of  pathogenic  organisms  from  the  lumen  of  the 
gut;  either  of  these  conditions  may  result  in  the  coverings  of  the  sac 
being  involved  in  the  inflammatory  process,  with  subsequent  rupture, 
allowing  the  escape  of  the  sac  contents  and  the  establishment  of  an 
artificial  anus. 

There  may  be  an  extension  of  the  peritonitis  in  the  hernial  sac  to 
the  general  abdominal  cavity,  or  the  above-mentioned  thrombosis 
of  mesenteric  vessels  supplying  intra-abdominal  segments  of  intestine 
may  occasion  a  primary  peritonitis  in  the  abdominal  cavity. 

In  cases  not  relieved  by  operation,  the  cause  of  death  in  the  vast 
majority  of  instances  is  the  existence  of  a  peritonitis  or  an  overwhelming 
toxemia  from  stasis. 

The  length  of  time  which  intervenes  between  the  onset  of  strangula- 
tion and  gangrene  of  the  gut  is  dependent  upon  a  number  of  factors: 
the  tightness  of  the  stricture,  the  age  and  general  condition  of  the 
patient,  and  according  to  Macready,  the  distance  below  the  stomach 
of  the  part  strangulated.     Cases  have  been  observed  in  which  gangrene 


916  HERNIA 

was  present  four  hours  after  the  onset  of  strangulation;  "it  is  rare 
before  twenty-four  hours,  and  is  delayer!  by  the  pressure  of  omentum 
in  the  sac"  (Blake). 

CLINICAL  VARIETIES  OF  HERNIA. 

Reducible  Hernia. — Symptoms. — Many  of  this  variety  give  a  history 
dating  from  birth  or  shortly  after  with  a  gradual  increase  in  size; 
others  appear  gradually  in  adult  life  and  may  be  unobserved  by  the 
patient  until  they  have  attained  considerable  size;  still  another  group 
are  brought  to  the  patient's  attention  for  the  first  time  following 
some  effort  or  strain  and  are  usually  accompanied  by  sharp,  lancinating 
pain. 

The  majority  of  cases  in  this  group,  however,  complain  only  of  a 
dragging  pain  or  a  .sense  of  fulness  at  the  site  of  the  hernia;  occasionally 
where  the  hernia  is  large,  reflex  gastric  or  intestinal  symptoms  may  be 
present. 

Depending  upon  the  site  and  the  size  of  the  tumor,  inspection 
usually  reveals  a  mass  which  descends  or  increases  in  size  upon  standing 
or  coughing,  and  may  be  spontaneously  reducible  upon  the  patients 
assuming  a  recumbent  position. 

In  practically  all  of  these  cases  a  distinct  impulse  upon  coughing 
or  crying  is  palpable,  and  the  examining  hand  may  be  able  to  determine 
the  contents  of  the  sac  either  at  the  time  when  it  is  driven  down  by 
the  impulse  of  coughing,  or  as  it  slips  back  under  the  examining  fingers 
as  the  patient  assumes  a  recumbent  position.  In  enteroceles  there  is 
usually  a  characteristic  gurgling  to  be  felt  and  sometimes  heard,  while 
the  epiploceles  have  in  most  cases  an  easily  recognizable  irregular 
or  nodular  feel.  Many  cases  which  are  not  spontaneously  reducible 
may  be  reduced  by  gentle  manipulation  on  the  part  of  the  surgeon. 

Percussion  over  an  enterocele  elicits  a  tympanitic  note,  while  that 
over  an  epiplocele  gives  a  dull  or  flat  note. 

Treatment. — Unless  there  are  special  contra-indications,  as  will  be 
pointed  out  in  the  discussion  of  the  anatomical  varieties,  hernias  of 
this  group  are  best  treated  by  operation  for  the  radical  cure  of  the  con- 
dition. Where  such  contra-indications  exist  they  should  be  treated 
by  a  mechanical  support  or  truss. 

Irreducible  Hernia. — The  early  history  in  this  group  of  cases  is 
usually  that  of  a  reducible  hernia,  which  has  either  been  neglected 
by  the  patient  or  subjected  to  repeated  trauma  of  an  ill-fitting  truss 
or  forcible  taxis,  with  the  end-result  that  it  is  no  longer  spontaneously 
reducible  and  cannot  be  reduced  by  any  effort  on  the  part  of  the 
patient  or  surgeon. 

Symptoms. — The  symptoms  of  this  group  differ  from  the  preceding 
only  in  the  point  of  irreducibility,  and  in  their  greater  tendency  to 
become  obstructed.  Ninety  per  cent,  of  all  irreducible  hernias 
contain  omentum  (Macready). 


CLINICAL   VARIETIES  OF  HERNIA  917 

Treatment. — Unless  there  be  marked  contra-indication  against  sub- 
jecting the  patient  to  any  operative  procedure,  operation  should  be 
promptly  carried  out  in  this  group  of  eases. 

In  the  cases  in  which  the  size  of  the  hernia  precludes  the  possibility 
of  its  return  to  the  abdominal  cavity  or  in  which  operative  contra- 
indications exist,  a  belt  or  truss  which  will  support  the  hernia  and 
prevent  any  increase  in  size  is  indicated. 

Inflamed  Hernia. — There  is  always  an  antecedent  history  either  of  a 
reducible  or  irreducible  hernia,  which  in  most  instances  has  been  trau- 
matized by  truss  or  taxis,  so  that  it  presents  in  addition  to  the  symp- 
toms of  its  original  condition,  those  of  pain,  tenderness,  redness,  and 
edema  over  the  site  of  protrusion,  frequently  accompanied  by  con- 
stitutional symptoms  of  fever  and  malaise.  There  may  be  vomiting 
and  constipation. 

Treatment. — Immediate  operation  is  indicated. 

Obstructed  Hernia. — In  this  group  of  cases  usually  there  is  an 
antecedent  history  of  a  large  reducible  or  irreducible  hernia  in  a  patient 
who  has  suffered  from  constipation. 

Symptoms. — The  onset  of  the  obstruction  is  coincident  with  an 
increase  of  constipation  which  becomes  marked  but  usually  not 
complete,  as  gas  may  be  passed.  The  abdomen  gradually  becomes 
distended  and  vomiting  ensues  late  and  usually  is  not  severe  and  not 
fecal  in  character.  There  is  an  increase  in  the  size  of  the  protrusion, 
and  a  hernia  which  formerly  may  have  been  reducible  becomes  irre- 
ducible. The  impulse  upon  coughing  can  still  be  obtained  best  near 
the  neck  of  the  sac.  The  hernia  becomes  painful,  and  of  somewhat 
doughy  consistency.  The  percussion  note  varies,  depending  upon  the 
presence  or  absence  of  gas,  from  dulness  to  tympany. 

If  this  condition  is  not  relieved,  strangulation  frequently  super- 
venes. 

Treatment. — Relief  may  be  had  in  some  cases  by  resorting  to 
enemata  and  taxis.  If  relief  is  not  speedily  forthcoming,  operative 
intervention  should  be  instituted. 

Strangulated  Hernia. — Symptoms. — There  is  usually  a  history  of  a 
previously  irreducible  hernia,  which  may  have  become  inflamed  or 
obstructed;  but  one  must  not  lose  sight  of  the  fact  that  it  is  possible 
for  a  hernia  to  become  strangulated  at  the  time  of  its  first  appearance. 

The  onset  of  strangulation  is  abrupt  and  is  usually  accompanied 
by  profound  shock.  Pain  is  present,  is  severe  and  colicky  in  character, 
and  is  frequently  referred  to  the  region  of  the  umbilicus.  With  the 
onset  of  the  pain,  the  patient  is  nauseated  and  vomits,  the  vomitus 
consisting  first  of  stomach  contents  and  bile-stained  fluid.  Constipa- 
tion is  absolute,  neither  gas  nor  feces  are  passed. 

As  the  condition  progresses,  there  may  be  a  continuation  of  the 
initial  vomiting,  which  is  probably  reflex  in  character,  or  there  may  be  a 
free  interval  between  this  and  the  vomiting  of  obstruction  which  is 
fecal  in  character  and  comes  on  later,  at  a  variable  time,  depending 


918 


HERNIA 


upon  the  portion  of  the  intestine  which  is  strangulated;  the  lower 
in  the  intestinal  canal  that  the  obstruction  exists,  the  later  the 
vomiting. 

With  the  onset  of  gangrene  there  is  a  subsidence  of  the  pain,  and 
usually  of  the  initial  reflex  vomiting. 

The  abdomen  becomes  distended,  the  degree  of  distension  depending 
upon  the  site  of  obstruction;  the  lower  the  obstruction  the  greater  it 
will  be. 

Locally. — There  is  pain  and  tenderness  at  the  site  of  the  protrusion. 
There  is  an  increase  in  size  of  the  hernia  which  becomes  more  tense. 
Impulse  is  lost.  (Where  the  strangulation  is  due  to  a  band  within  a 
hernial  sac,  an  impulse  may  be  obtained  from  the  non-strangulated 
portion  of  the  sac.) 

In  rare  cases  the  overlying  skin  may  become  red  and  infiltrated. 
The  pulse  is  rapid  and  later  becomes  feeble  and  irregular.  Tempera- 
ture may  be  subnormal  or  slightly  elevated  at  the  onset,  but  rises 
later  with  the  onset  of  gangrene. 


]Ji  rita/it/j?n 
!   ,  Vt/st/c  &  fascia 
:  Skirt  &  Subcutaneous 


Fig.  442. — Partial  enterocele,  or  Richter's  hernia.     (Ashhurst.) 


In  certain  varieties  of  strangulated  hernia,  the  typical  symptoms  may 
not  be  elicited.  Eccles  has  tabulated  a  group  of  conditions  under 
which  strangulation  has  been  found  to  exist  accompanied  by  atypical 
symptoms.  This  tabulation  subsequently  modified  by  Blake  is  as 
follows: 

I.  Cases  in  which  the  peculiarities  are  dependent  upon  the  contents 
of  the  sac. 

1.  Strangulation  of  a  portion  of  the  bowel. 

(a)  Partial  enterocele  (Richter's  hernia)  (Fig.  442). 

(b)  Strangulation  of  the  vermiform  appendix. 

(c)  Strangulation  of  Meckel's  diverticulum  (Littre's  hernia)  (Fig. 

443). 
In  this  group  the  obstructive  symptoms  are  usually  absent. 

2.  Strangulation  within  the  body  of  the  sac. 

(a)  By  bands,  adhesions,  apertures  in  the  omentum,  etc. 

(b)  By  kinking  or  volvulus. 


CIJX/CAL   VARIETIES   OF   IIEh'XIA 


DID 


II.  Cases  in  which  the  peculiarities  are  dependent  upon  the  sac. 
(a)  Strangulation  within  a  loculus  or  a  pouch  within  the  sac. 

III.  Retrograde  incarceration  or  hernia  "En  IT." — In  this  condition 
the  two  lateral  limbs  of  the  "  W"  are  formed  by  segments  of  gut  in 
which  the  circulation  is  normal  or  but  slightly  impaired  and  which  lie 
in  the  sac,  while  the  middle  or  connecting  loop  of  the  "W"  lies  within 
the  abdomen  and  is  gangrenous,  its  mesentary  being  constructed  at 
the  neck  of  the  sac. 

It  may  be  found  difficult  to  diagnosticate  properly  the  existence  or 
site  of  strangulation  under  any  of  the  following  conditions: 

1.  Where  a  strangulated  hernia  is  present  at  one  hernia  site  and  an 
irreducible  hernia  at  another.  Both  hernias  may  have  existed  for 
some  time,  or  one  may  be  recent  and  strangulated  at  the  time  of  its 
occurrence. 

2.  Where  there  is  an  irreducible  hernia  in  a  patient  with  obstruction 
or  strangulation  from  some  other  intra-abdominal  cause. 


Fig.  443. — Littre's  hernia — a  hernia  of  one  of  the  intestinal  diverticula  (Meckel's 
diverticulum) .      (Ashhurst.) 

3.  Where  one  hernia  conceals  another,  as  a  large  and  a  small 
epigastric  hernia  situated  close  together. 

4.  Where  there  is  an  inguinal  and  a  femoral  hernia  on  the  same  side, 
one  strangulated,  and  the  other  not. 

The  local  physical  signs,  however,  are  usually  sufficient  to  indicate 
which  hernia  is  strangulated  where  two  or  more  hernias  coexist. 

Treatment. — Treatment  is  either  by  taxis  or  by  repair  of  the  hernia. 

Taxis. — By  taxis  is  meant  the  replacement  of  the  hernial  protrusion 
by  manipulation.  Reduction  by  this  means  may  be  facilitated  by  a 
posture  which  would  permit  gravity  to  act  and  would  also  help  to 
obtain  muscular  relaxation  at  the  site  of  the  hernia,  i.  e.,  in  inguinal 
or  femoral  hernia,  these  conditions  would  be  fulfilled  with  the  patient 
in  the  dorsal  position  with  the  foot  of  the  bed  raised,  with  the  thigh 
rotated  inward  and  flexed  upon  the  pelvis. 

Muscular  relaxation  also  may  be  obtained  by  immersing  the  patient 
in  a  warm  bath,  or  best  by  the  administration  of  an  anesthetic.     In 


920  HERNIA 

addition  to  the  above,  support  of  the  neck  of  the  sac  with  one  hand 
while  gentle  pressure  is  exerted  over  the  fundus  of  the  sac  with  the 
other  in  the  direction  of  the  canal  through  which  the  sac  escaped,  is 
frequently  enough  to  effect  a  reduction. 

Taxis  should  always  be  carried  out  with  the  greatest  possible  gentle- 
ness and  never  should  be  prolonged  over  five  minutes.  There  are 
certain  dangers  associated  with  taxis  which  should  be  appreciated, 
among  them  are: 

1 .  Rupture  of  gangrenous  gut,  or  rupture  or  damage  to  the  gut  which 
was  still  viable  at  the  time  taxis  was  performed. 

2.  Return  of  a  segment  of  non- viable  gut  to  the  abdominal  cavity. 

3.  Return  of  septic  contents  of  the  sac  to  the  peritoneal  cavity. 

4.  Reduction  en  masse  without  the  relief  of  the  constriction  at  the 
neck. 

There  are  certain  conditions  under  which  taxis  should  not  be 
attempted .     These  are : 

1.  Where  the  hernia  was  known  to  be  irreducible  previous  to  the 
onset  of  strangulation. 

2.  Where  it  has  been  tried  once  and  failed. 

3.  Where  the  patient  is  in  a  condition  of  profound  shock. 

4.  YN  here  there  is  reason  to  believe  the  gut  is  gangrenous,  or  where 
the  strangulation  has  existed  for  twenty-four  hours. 

5.  Where  the  superficial  tissues  are  inflamed. 

Operative  Treatment. — This  is  the  procedure  of  choice  in  a  case  of 
strangulated  hernia.  Where  the  condition  of  the  patient  is  such  that  the 
administration  of  a  general  anesthetic  is  thought  unwise,  many  cases 
can  be  successfully  operated  upon  under  local  anesthesia  alone,  or  sup- 
plemented with  the  administration  of  morphine.  Open  operation  per- 
mits of  inspection  of  the  strangulated  loop,  the  removal  of  obstacles  to 
reduction,  the  determination  as  to  the  viability  of  the  strangulated 
loop  and  also  of  adjacent  intra-abdominal  segments,  the  prevention 
of  septic  contents  being  returned  to  the  peritoneal  cavity.  The 
prevention  of  reduction  en  masse,  resection  of  gut  if  necessary,  and  it 
also  permits  the  radical  cure  of  the  hernia. 

Procedure. — The  coverings  of  the  sac  are  divided  by  an  incision 
similar  to  that  which  would  be  made  for  the  radical  cure  of  the  hernia, 
thus  exposing  the  sac,  which  is  carefully  opened,  allowing  any  fluid 
to  escape  and  permitting  a  full  view  of  the  contents,  which  should  be 
flushed  with  sterile  salt  solution  to  minimize  the  danger  of  contami- 
nating the  peritoneal  cavity. 

The  constriction  causing  the  strangulation  is  next  divided  and  the 
contained  and  adjacent  proximal  and  distal  segments  of  gut  drawn 
downward  and  examined  to  determine  their  viability.  If  the  condition 
of  the  gut  is  satisfactory  it  may  be  returned  to  the  abdominal  cavity 
and  the  operation  for  the  radical  cure  completed.  If  the  intestine  is 
obviously  gangrenous  or  damaged  to  such  an  extent  that  its  return  is 
deemed  unsafe,  one  of  two  procedures  may  be  carried  out:  resection 


ANATOMICAL   VARIETIES  OF  HERNIA 


921 


with  reunion  immediately,  or  the  establishing  of  an  artificial  anus. 
Statistics  prove  the  first  of  these  procedures  to  be  preferable. 

There  is  a  third  group  made  up  of  those  cases  in  which  upon  opening 
the  sac  there  is  doubt  in  the  operator's  mind  as  to  whether  the  gut  is 
viable  or  not.  In  these  cases  the  relief  of  the  constriction  and  the 
surrounding  of  the  suspected  loop  with  sterile  pads  moistened  with  hot 
saline  for  five  or  ten  minutes  will  frequently  determine  the  procedure. 

In  case  a  resection  is  indicated  in  a  strangulated  femoral  hernia  it 
will  be  found  more  convenient  to  carry  out  this  procedure  through  a 
separate  abdominal  incision,  preferably  through  the  rectus. 


^ 

■  mSSm   ■ 

Fig.  444. — Hydrocele  and  inguinal  hernia. 


ANATOMICAL  VARIETIES  OF  HERNIA. 


Anatomically  hernias  are  designated  as  inguinal,  femoral,  umbilical; 
ventral  hernia  of  the  linea  alba,  (a)  epigastric,  (6)  hernia  below  the 
umbilicus;  diastasis  of  recti;  traumatic  ventral  hernia;  hernia  of  the 
linea  semilunaris;  lumbar,  ischiatic,  diaphragmatic,  obturator  hernia 
of  the  pelvic  outlet;  and  hernia  through  the  linea  transversa?. 

Inguinal  Hernia. — This  term  refers  to  all  hernias  through  or  into 
the  inguinal  canal.  They  may  be  subdivided  into  three  groups:  (1) 
indirect  or  oblique,  (2)  direct,  and  (3)  interstitial. 

Indirect  or  Oblique  Inguinal  Hernia. — This  is  the  commonest  variety 
of  inguinal  hernia,  constituting  93  per  cent,  of  the  hernias  in  this  region. 
Most  recent  authors  agree  that  in  "the  vast  majority  of  inguinal 


922 


HERNIA 


hernias  in  the  male,  and  practically  all  in  the  female,  the  sac  is  pre- 
formed, there  being  an  open  funicular  process  of  peritoneum  existing  at 
birth,  though  the  hernia  may  not  develop  until  adult  life." 


Fig.  445. — Congenital 
hernia. 


Fig.  446.— Infantile 
hernia. 


Fig.  447. — Acquired 
hernia. 


The  term  congenital  hernia  has  been  applied  to  those  cases  in 
which  the  hernia  descends  into  the  unobliterated  processus  vaginalis, 
in  either  the  male  or  female. 


Fig.  448. — Left  inguinal  hernia. 

The  term  infantile  hernia  is  used  to  designate  that  type  of  acquired 
hernia  in  which  the  sac  formed  from  the  parietal  peritoneum  protrudes 
from  the  side  of  the  patient  or  partially  obliterated  processus  vaginalis. 

In  the  ordinary  acquired  variety  of  oblique  inguinal  hernia  the 
protruding  viscus  in  its  descent  through  the  inguinal  canal  pushes 
in  front  of  it,  not  only  its  own  sac  of  peritoneum  and  fatty  tissue, 
but  also  a  process  of  the  transversalis  fascia  and  the  cremasteric  fascia. 


ANATOMICAL   VARIETIES  OF  HERNIA 


923 


As  it  emerges  from  the  external  abdominal  ring  it  enters  the  process 
of  the  intercolumnar  fascia  which  incloses  the  cord,  and  finally 
descends  into  the  scrotum,  where  it  is  covered  by  the  dartos  and  skin 
(Fig.  4 48).     This  is  the  adult  type  of  the  disease. 

An  indirect  hernia  is  said  to  be  incomplete  {bubonocele)  when  the 
protrusion  occupies  the  inguinal  canal.  It  is  called  complete  or  scrotal 
in  the  male,  and  complete  or  labial  in  the  female,  wdien  it  reaches  the 
bottom  of  the  scrotum  in  the  male  or  labium  in  the  female. 

Diagnosis. — The  subjective  and  objective  symptoms  of  a  reducible 
hernia  (see  above)  are  usually  present.  It  may  be  necessary  to 
differentiate  an  incomplete  indirect  hernia  from  any  of  the  following 


Fig.  449. — Large  scrotal  hernia.     (Richardson.) 

conditions:  Hydrocele  of  the  cord  or  canal  of  Nuck,  femoral  hernia, 
inguinal  adenitis  or  abscess,  psoas  abscess,  new  growth  of  the  inguinal 
glands,  undescended  testicle,  lymphangiectasis  of  the  inguinal  lym- 
phatics secondary  to  filariasis. 

A  complete  indirect  hernia  may  be  confused  with  the  following: 
a  hydrocele  of  the  tunica  vaginalis,  varicocele,  hematocele,  inflam- 
matory conditions  of  the  testis,  and  epididymis,  new  growths  of  the 
testicle  and  epididymis. 

Treatment. — Treatment  may  be  either  by  mechanical  means,  such  as 
a  truss,  so  arranged  as  to  exert  an  even  pressure  over  the  point  of  exit 
of  the  hernia,  i.  e.,  over  the  internal  ring;  or  by  an  operation  for  the 
radical  cure.     Mechanical  treatment  gives  its  best  results  where  it  is 


924  HERNIA 

used  during  the  first  year  of  life;  a  spring  truss  being  most  effective  in 
infancy. 

Later  in  life  treatment  by  mechanical  means  is  best  reserved  for 
those  eases  in  which  there  is  some  contra-indication  to  operation. 

Operation  for  the  Radical  Cure  of  Inguinal  Hernia. — Many  operations 
have  been  devised  for  the  cure  of  this  condition  but  none  have  stood 
the  test  of  time  as  well  as  the  Bassini  which,  with  slight  modifications 
adapted  to  an  individual  case,  is  best  suited  to  give  uniformly  satis- 
factory results.     The  steps  of  the  operation  are  as  follows: 

An  incision  is  made  2  cm.  above  Poupart's  ligament  and  parallel 
with  it,  beginning  at  a  point  corresponding  to  the  internal  ring  and 
extending  to  the  centre  of  the  external  ring.  The  structures  are  divided 
down  to  the  aponeurosis  of  the  external  oblique  muscle  and  the  external 
ring  exposed.  A  grooved  director  is  then  passed  into  the  canal  from 
the  external  ring,  and  upon  this  the  aponeurosis  is  split  in  the  direction 
of  its  fibres  for  a  distance  of  5  to  7  cm.  The  upper  flap  of  the  aponeu- 
rosis is  next  stripped  from  the  internal  oblique  and  the  sheath  of  the 
rectus  for  a  distance  of  2.5  to  3.5  cm.  This  separation  makes  it  easier 
subsequently  to  bring  down  the  lower  edge  of  the  internal  oblique. 


Fig.  450.- — Spring  truss. 

The  lower  flap  is  next  freed  on  its  under  surface  from  the  coverings 
of  the  cord  and  sac,  and  the  shelving  border  of  Poupart's  ligament  is 
well  exposed  as  far  as  its  insertion.  The  sac  is  then  exposed  at  its 
uppermost  portion,  the  overlying  cremasteric  and  transversalis  fascia 
being  divided  by  sharp  dissection,  which  is  continued  until  the  neck 
of  the  sac  is  isolated  from  the  cord.  This  accomplished  the  remainder 
of  the  sac  may  be  separated  from  the  cord  by  pushing  with  gauze  or 
by  sharp  dissection.  Any  bleeding  vessels  should  be  instantly  ligated 
and  the  cord  handled  with  extreme  gentleness  to  avoid  subsequent 
swelling.  After  the  sac  is  freed  from  the  surrounding  tissues  it  is 
opened  and  the  contents  reduced.  Existing  adhesions  should  be 
divided  and  redundant,  inflamed  or  damaged  omentum  resected 
after  a  chain  ligation.  The  sac  is  now  exposed  to  insure  its  emptiness, 
its  neck  drawn  outward  and  securely  ligated  with  a  transfixation  suture 
of  catgut  (Fig.  451),  the  distal  portion  removed  (except  in  congenital 
hernia,  where  the  lower  portion  is  ligated  or  sutured  to  form  a  tunica 
vaginalis  for  the  testicle),  the  stump  is  allowed  to  sink  into  the 
abdominal  cavity.     Sometimes  the  neck  of  the  sac  is  so  bulky  or  of 


ANATOMICAL   VARIETIES  OF   HERMA 


925 


such  shape  that  ligation  is  impossible.     In  these  cases  the  neck  of  the 
sac  is  closed  by  suture  and  the  distal  portion  removed. 

The  cord  is  now  freed  and  retracted  to  the  outer  part  of  the  wound. 
Several  deep  sutures  of  Kangaroo  tendon  or  chromicized  catgut  are 


Fig.  451. — Operation  for  the  radical  cure  of  inguinal  hernia  (Bassini's  method): 
a,  sac  dissected  from  the  cord,  opened,  examined,  and  neck  ligated;  b,  cord;  c,  Poupart's 
ligament;   d,  arched  fibres  of  internal  oblique  muscle;    e,  transversalis  fascia.      (Bryant.) 


Fig.  452. — Operation  for  the  radical  cure  of  inguinal  hernia  (Bassini's  method) : 
sac  removed  (c),  cord  drawn  aside,  and  stitching  of  lower  fibres  of  the  internal  oblique 
and  transversalis  muscles  (6)  to  Poupart's  ligament  (d)  from  without  inward;  o,  trans- 
versalis fascia.     (Bryant.) 

then  passed  through  the  whole  thickness  of  the  lower  border  of  the 
internal  oblique  and  the  deep  layer  of  Poupart's  ligament,  the  first 
stitch  being  taken  on  the  inner  side  of  the  cord  in  such  a  manner  that 


J)2(i 


HERNIA 


the  suture  should  just  touch  the  cord  when  it  is  held  up  at  right  angles 
to  the  wound.  The  remaining  sutures,  usually  three  or  four  in  number, 
unite  the  internal  oblique  and  Poupart's  ligament  as  far  as  the  spine  of 
the  pubis,  where  the  inner  portion  of  the  internal  oblique  is  deficient. 
The  last  stitch  can  include  the  conjoined  tendon  and  the  margin  of 
the  rectus  (Figs.  452  and  453). 

After  the  structures  are  snugly  drawn  together  and  the  sutures 
knotted,  reconstructing  the  floor  of  the  inguinal  canal,  the  cord  is 
allowed  to  drop  into  place.  Some  operators  put  a  suture  on  the  outer 
side  of  the  cord  with  the  idea  of  giving  the  muscular  fibres  a  lower 
plane  at  their  origin,  and  placing  the  point  of  emergence  of  the  cord  at 
a  greater  distance  from  the  internal  abdominal  ring,  giving  the  latter 


Fig.  453. — Operation  for  the  radical  cure  of  inguinal  hernia  (Bassini's  method): 
arched  muscular  fibres  and  conjoined  tendon  (b)  sewed  to  Poupart's  ligament  (a);  c, 
aponeurosis  of  external  oblique  muscle.     (Bryant.) 

additional  protection.     When  this  suture  is  used  it  should  be  the 
first  to  be  introduced  and  tied. 

The  roof  of  the  canal  is  now  made  by  uniting  the  divided  external 
oblique  aponeurosis  with  a  continuous  suture  of  fine  catgut  which 
should  be  carried  down  to  a  point  which  leaves  only  enough  of  the 
external  ring  open  to  allow  the  cord  to  pass  outward  without  con- 
striction (Fig.  454).  The  skin  wound  is  closed  and  the  dressing  ap- 
plied. Some  operators  have  modified  this  technic  by  allowing  the 
cord  to  remain  beneath  the  deep  layer  of  sutures  uniting  the  internal 
oblique  muscle  to  Poupart's  ligament,  emerging  at  the  external  ring. 
This  modification  should  be  used  where  the  transversalis  fascia 
forming  the  dorsal  wall  of  the  inguinal  canal  is  well  developed,  as  is 
apt  to  be  the  case  in  small  and  oblique  hernia,  and  when  the  internal 


ANATOMICAL   VARIETIES  OF  HERNIA 


927 


oblique  muscle  is  well  developed  and  can  be  easily  brought  down  to 
Poupart's  ligament. 

Adult  patients  should  remain  in  bed  from  three  to  four  weeks. 
Children  under  fourteen  years  of  age  from  two  to  three  weeks. 

Ilalsted's  operation  differs  from  the  Bassini  procedure  in  that  he 
divides  the  fibres  of  the  internal  oblique  above  the  internal  ring,  draws 
the  cord  outward  at  the  upper  angle  of  the  wound,  unites  all  the  deeper 
tissues,  fascia  muscles  and  aponeuroses  to  Poupart's  ligament  by  a 
single  row  of  mattress  sutures  of  silver  wire,  removes  the  superficial 
veins  of  the  cord  and  allows  it  to  pass  from  the  upper  angle  of  the 
wound  to  the  scrotum  between  the  muscles  and  the  skin  (Fig.  455) . 


Fig.  454. — Operation  for  the  radical  cure  of  inguinal  hernia  (Bassini's  method) : 
aponeurosis  of  external  oblique  (a)  sewed  with  continuous  sutures  to  Poupart's  ligament 
(b).     (Bryant.)  • 


Bloodgood's  operation  is  a  modification  of  Halsted's  and  consists 
in  exposing  the  outer  fibres  of  the  rectus  muscle  by  a  division  of  the 
posterior  layer  of  the  sheath,  and  including  it  in  the  lower  three  or  four 
deep  sutures,  thus  reinforcing  the  often  thin  and  weakened  fibres  of 
the  internal  oblique  (Fig.  456). 

Direct  Hernia. — Direct  hernia  is  comparatively  rare,  the  protrusion 
taking  place  through  Hesselbach's  triangle  or  that  space  in  the  lower 
abdominal  wall  bounded  by  the  sheath  of  the  rectus  muscle,  the 
deep  epigastric  artery,  and  Poupart's  ligament.  If  the  protrusion 
occurs  in  the  outer  half  of  this  space,  between  the  epigastric  and  the 
obliterated  hypogastric  artery,  the  hernia  will  have  practically  the 
same  coverings  as  an  oblique  inguinal  hernia,  if  it  occurs  through  the 
inner  half  of  the  space  it  may  carry  with  it  a  tunic  made  up  of  the 
denser  portion  of  the  transversalis  fascia,  with  or  without  a  few  fibres 


928 


HERNIA 


of  the  conjoined  tendon,  or  it  may  force  its  peritoneal  and  subperitoneal 
coverings  beneath  or  between  the  fibres  of  this  structure  and  receive 
only  an  investment  of  the  intercolumnar  fascia. 

In  the  direct  hernia  the  sac  generally  lies  behind  or  to  the  inner  side 
of  the  cord,  and  the  two  may  not  be  contained  in  the  same  fascial 
sheath. 


Fig.  455. — Operation  for  the  radical  cure  of  inguinal  hernia  (Halsted's  method): 
veins  ligated  and  resected;  silver  sutures  inserted,  one  above  and  four  below  the  cord. 
(Bryant.) 


This  type  of  hernia  constitutes  about  7  per  cent,  of  the  inguinal 
hernias,  is  more  common  in  men  than  in  women  and  is  seldom  complete. 

Treatment  is  the  same  as  for  the  indirect  variety  with  the  exception 
that  where  there  is  a  large  undefended  space,  as  frequently  occurs 
in  direct  hernia  with  the  lower  border  of  the  internal  oblique  a  con- 
siderable distance  above  Poupart's  ligament.     Blake  has  transplanted 


ANATOMICAL   VARIETIES  OF  HERNIA 


'.)_".  I 


the  rectus  muscle,  exposing  the  muscle  by  the  Bloodgood  method 
of  slitting  its  deep  or  dorsal  sheath,  has  sutured  the  rectus  to 
Poupart's  ligament  first  and  then  brought  the  internal  oblique  down 
in  front  of  it,  as  in  the  Bassini  operation.  The  reason  for  this  pro- 
cedure is  that  bringing  down  the  rectus  lowers  the  insertion  of  the 


ATTACHMENT  OF  RECTUS'" 
TO  SYM.  PUB. 

SPINE  PUB! 


Fig.  456. — Operation  for  the  radical  cure  of  inguinal  hernia  (Bloodgood's  modifica- 
tion of  Halsted's  method);  cord  removed  so  as  not  to  obscure  demonstration:  a,  a, 
divided  borders  of  internal  oblique  muscle;    b,  b  ,  ends  of  resected  cord.     (Bryant.) 


internal  oblique,  thus  permitting  the  suturing  to  Poupart's  ligament 
with  much  less  tension. 

Interstitial  Hernia. — This  is  a  form  of  hernia  in  which  the  protruded 
mass  in  its  descent  does  not  follow  the  direction  of  an  ordinary  inguinal 
hernia  but  is  found  to  occupy  one  of  three  locations: 
59 


o:;o 


HERNIA 


1.  Between  the  internal  oblique  and  the  aponeurosis  of  the  external 
oblique. 

2.  Between  the  external  oblique  aponeurosis  and  the  skin. 

3.  Between  the  peritoneum  and  the  transversalis  fascia  (projieri- 
loneal  hernia). 

Occasionally  two  distinct  but  communicating  sacs  are  present,  one 
entering  the  scrotum  in  the  usual  manner  and  the  other  in  one  of  the 
abnormal  situations  just  described.  In  many  cases  of  the  third 
variety  where  the  protrusion  exists  between  the  peritoneum  and  the 


Fig.  457. — Operation  for  the  radical  cure  of  inguinal  hernia  (Bloodgood's  modifi- 
cation of  Halsted's  method) :  the  transplanted  border  of  the  rectus  united  to  Poupart's 
ligament,  showing  slight  change  in  the  direction  of  its  fibres.     (Bryant.) 


transversalis  fascia,  no  tumor  is  present,  and  exact  diagnosis  is  often 
impossible  before  operation.  Associated  with  this  variety  there  is,  in 
the  majority  of  cases,  a  scrotal  or  labial  hernia. 

Occasionally  a  preperitoneal  hernia  is  produced  by  the  apparent 
reduction  of  an  incarcerated  inguinal  or  femoral  hernia,  the  so-called 
reduction  en  masse,  the  entire  sac  and  its  contents  being  pushed 
backward  through  the  ring  between  the  muscles  and  the  parietal 
peritoneum  where  it  remains  still  constricted  by  the  neck  of  the 
peritoneal  sac. 


ANATOMICAL  VARIETIES  OF  HERNIA  931 

The  frequency  with  which  interstitial  hernia  is  associated  with  an 
undescended  testicle  has  been  variously  estimated  by  different  authors. 
Macready  states  that  67  per  cent,  of  the  cases  occurring  in  males  are 
accompanied  by  a  wholly  retained  or  partially  descended  testicle. 
While  in  those  cases  in  males  observed  by  Langdon  95  per  cent,  showed 
an  undescended  testicle.  "  The  most  characteristic  point  of  all  forms 
of  interstitial  hernia  is  their  association  with  some  form  and  degree  of 
crypt  orchidism"  (Moschowitz) . 

Femoral  Hernia. — This  variety  of  hernia  is  less  frequent  than  the 
inguinal,  the  proportion  being  about  one  of  the  femoral  to  seventeen 
of  the  inguinal.  It  rarely  occurs  as  a  congenital  affection,  and  is 
generally  observed  in  adult  females.  The  stretching  of  the  fascia  in 
this  region  by  repeated  pregnancies  and  the  fact  that  the  canal  is 
larger  in  women,  constitute  predisposing  causes  for  this  sex.  A  femoral 
hernia  has  been  known  to  follow  an  operation  for  the  repair  of  an 
inguinal  hernia  because  of  the  pulling  up  of  Poupart's  ligament  by  the 
muscles  sutured  to  it,  thus  enlarging  the  canal. 

The  protrusion  leaves  the  abdominal  cavity  at  a  point  just  beneath 
Poupart's  ligament  and  to  the  inner  side  of  the  femoral  vein.  It 
enters  a  membranous  pouch  called  the  femoral  canal,  which  is  the 
inner  compartment  of  the  femoral  sheath.  This  canal  extends  down- 
ward by  the  side  of  the  femoral  vein  to  the  saphenous  opening  of  the 
fascia  lata.  (In  rare  instances  the  hernia  may  descend  in  front  of 
the  vessels  or  even  on  their  lateral  aspect.)  In  its  descent  the  sac  of 
the  hernia  carries  before  it  a  thickened  pouch  of  the  subserous  cellular 
tissue,  called  the  septum  crurale.  As  it  emerges  at  the  saphenous 
opening  it  also  receives  an  investment  from  the  cribriform  fascia. 
Recently  developed  femoral  hernias  may  be  covered  only  by  the  skin, 
superficial  fascia,  and  a  single  layer  of  dense  membrane,  called  by 
Cooper  the  fascia  propria  which  results  from  a  fusion  of  the  septum 
crurale  and  the  cribriform  fascia.  In  long-standing  cases  dissection 
will  occasionally  reveal  several  layers  which  are  probably  the  result 
of  an  inflammatory  process. 

The  neck  of  a  femoral  hernia  is  in  relation  anteriorly  with  Poupart's 
ligament,  posteriorly  with  the  pectineal  fascia,  externally  with  the 
femoral  vein,  internally  with  Gimbernat's  ligament.  As  mentioned 
above  the  possibility  of  the  obturator  artery  being  in  relation  to  the 
neck  of  the  sac  should  be  borne  in  mind. 

When  the  hernial  protrusion  emerges  from  the  saphenous  opening, 
it  is  directed  upward  and  outward  by  the  attachment  of  the  cribriform 
fascia.  This  causes  the  tumor  to  overlie  the  ligament  and  to  occupy  a 
position  at  or  near  the  site  of  an  incomplete  inguinal  hernia  often 
rendering  the  diagnosis  difficult.  The  hernial  tumor  is  generally 
small,  and  more  often  contains  omentum  than  intestine.  Occasionally 
an  ovary,  the  Fallopian  tube,  the  bladder,  or  the  appendix  will  be 
found  in  the  sac  of  a  femoral  hernia.  Strangulation  occurs  relatively 
more  often  than  in  inguinal  hernia. 


932  HERNIA 

A  femoral  hernia  rarely  gives  rise  to  subjective  symptoms  until  it 
becomes  inflamed  or  strangulated.  Exceptionally  there  is  pain  either 
locally  or  in  the  neighborhood  of  the  umbilicus,  and  a  sense  of  weight 
or  dragging  in  the  groin.  In  the  majority  of  instances  the  presence  of 
a  small  oval  tumor  in  the  groin  is  the  first  sign  of  the  disease.  In 
corpulent  individuals  this  is  often  overlooked,  and  the  first  indication 
of  a  hernia  may  be  the  symptoms  of  strangulation. 

Diagnosis. — The  presence  of  a  rounded  swelling  in  the  groin  just 
below  Poupart's  ligament  and  to  the  inner  side  of  the  femoral  vessels, 
which  is  resonant  on  percussion,  which  has  a  distinct  impulse  on  cough- 
ing, and  which  can  be  reduced  with  a  gurgling  sound,  may  with  cer- 
tainty be  diagnosticated  femoral  hernia.  In  the  majority  of  cases, 
however,  one  or  more  of  these  signs  are  absent;  thus  in  femoral  epiplo- 
celes  the  tumor  lacks  resonance,  in  incarcerated  hernia  the  impulse 
may  be  wanting,  and  in  many  others  the  tumor  may  rise  above  Pou- 
part's ligament  and  in  fleshy  individuals  the  exact  position  of  the  neck 
of  the  sac  is  difficult  to  appreciate. 

Femoral  adenitis  may  be  excluded  by  the  absence  of  the  impulse 
and  resonance  and  by  the  fact  that  the  glandular  mass  is  hard,  often 
movable,  frequently  inflamed,  and  generally  associated  with  other 
enlarged  glands.  A  small  lipomatous  mass  is  occasionally  present  in 
this  region  and  may  closely  resemble  a  small  incarcerated  epiplocele. 
Small  lipomata  may  occasionally  be  present  with  a  femoral  hernia. 

Psoas  abscess  and  saphenous  varix  may  present  an  impulse  on  cough- 
ing and  disappear  on  lying  down,  the  former  generally  can  be  felt 
above  the  iliac  fossa,  and  is  associated  with  Pott's  disease;  the  latter  is 
commonly  associated  with  varices  of  the  lower  leg. 

Treatment. — Inasmuch  as  this  variety  of  hernia  is  practically  incur- 
able by  mechanical  means  and  the  operative  treatment  is  simple,  and 
by  it  a  permanent  cure  is  nearly  always  obtained,  operation  should  be 
advised  unless  contra-indicated  by  special  considerations. 

Operations-  for  Femoral  Hernia. — A  large  number  of  femoral  hernias 
are  cured  by  the  simple  operation  of  herniotomy  for  the  relief  of 
strangulation. 

If  after  the  bowel  is  returned  to  the  abdominal  cavity  the  sac  is 
separated,  ligated,  and  cut  off,  the  femoral  canal  emptied  by  pushing 
the  stump  of  the  sac  well  backward  into  the  abdominal  cavity,  and  its 
walls  approximated  by  almost  any  kind  of  suture,  recovery  will  be 
likely  to  follow.  The  fact  apparently  has  been  overlooked  by  many 
surgeons  who  have  devised  more  or  less  complicated  and  difficult 
operations  which  have  for  their  object  obliteration  of  the  femoral 
canal  by  transplantation  of  muscle  or  by  means  of  some  plastic  opera- 
tion from  above.  These  procedures  are  objectionable,  in  that  they 
are  technically  difficult,  often  necessitate  the  opening  of  an  intact 
inguinal  canal,  and  are  wholly  unnecessary,  for  Coley  has  recently 
reported  a  series  of  125  operations  by  the  simple  purse-string  suture 
without  a  single  relapse,  more  than  half  of  his  cases  having  already 


ANATOMICAL   VARIETIES  OF  HERNIA 


«.):;:; 


passed  the  two-year  limit.  As  the  statistics  of  the  Hospital  for  the 
Rupture,  and  Crippled  show  that  practically  90  per  cent,  of  relapses 
after  operations  upon  all  varieties  of  hernia  occur  within  the  first  year, 
there  seems  to  be  no  reason  for  employing  the  more  complicated 
methods.  Several  methods  of  approximating  the  walls  of  the  femoral 
canal  are  in  general  use. 

The  Cushing  purse-string  method  consists  simply  in  the  introduction 
of  a  purse-string  suture  of  chromicized  catgut  around  the  margin  of 
the  saphenous  opening.  The  needle  is  introduced  through  the  inner 
portion   of  Poupart's  ligament,   then  through  the  pectineal  fascia, 

r 


Fig.  458. — Obliteration  of  the  femoral  opening  by  purse-string  suture.     (Coley.) 


then  passed  upward  along  the  inner  border  of  the  femoral  vein,  and 
outward  near  the  original  point  of  entrance.  When  this  is  drawn  tight 
and  knotted  the  lowrer  portion  of  the  canal  is  obliterated.  (Fig.  458.) 
The  Blake  operation  has  for  its  object  the  obliteration  of  the  upper 
portion  of  the  canal.  A  mattress  suture  is  passed  from  above  Pou- 
part's ligament  downward  through  Cooper's  ligament  and  out  of  the 
lowrer  opening  of  the  canal,  then  upward  near  the  margin  of  the  femoral 
vein,  through  the  same  structures  and  emerging  again  above  Poupart's 
ligament.  When  this  structure  is  tied  the  upper  extremity  of  the  canal 
is  closed.  The  lowre  margin  of  the  canal  can  then  be  united  to  the 
pectineal  fascia  by  a  few  interrupted  sutures  (Fig.  459). 


934 


HERNIA 


Umbilical  Hernia. — Under  this  heading  there  are  three  varieties  to 
consider : 

1.  Congenital  hernia  of  the  cord. 

2.  Infantile  umbilical  hernia. 

3.  Adult  umbilical  hernia. 

Congenital  Hernia  of  the  Cord  is  an  extremely  rare  condition,  occur- 
ring, according  to  Linfors,  once  in  5184  cases.  To  understand  this 
variety  one  must  recall  the  conditions  which  obtain  in  early  embryonic 
life.  At  the  eighth  to  tenth  week  of  fetal  life,  a  portion  of  the  intestine 
occupies  a  position  in  the  cavity  of  the  umbilical  cord,  but  at  a  later 


Fig.  459. — Blake's  operation  for  femoral  hernia.  Mattress  stitch  in  place  and  tied. 
Stitches  to  close  lower  opening  of  femoral  canal  inserted,  but  not  tied:  a,  mattress 
stitch;  b,  round  ligament;  c,  Poupart's  ligament;  d,  falciform  process;  e,  fascia  of 
pectineus;    /,  femoral  vein. 


period,  it  recedes  to  permit  an  agglutination  of  the  visceral  plates  in 
this  region,  which  normally  effect  a  closure  anteriorly  and  form  the 
umbilicus. 

The  term  umbilical  hernia  for  this  variety  of  protrusion  is  really 
a  misnomer,  for  at  the  time  of  its  incidence  no  umbilicus  has  been 
formed,  and  it  should  more  properly  be  regarded  as  an  imperfect 
inclosure  of  the  viscera  by  the  abdominal  wall. 

The  coverings  of  this  type  of  hernia  consist  of  (1)  a  layer  of  Whar- 
ton's jelly,  (2)  a  thin  sac  which  is  continuous  with  the  peritoneum. 
In  most  cases  the  coverings  are  sufficiently  transparent  to  permit  of 
the  contents  being  easily  seen. 


ANATOMICAL   VARIETIES  OF  HERNIA 


935 


In  size  they  vary  from  a  tiny  protrusion  to  almost  complete 
evisceration. 

Treatment. — The  only  cases  which  are  amenable  to  treatment  are 
those  which  are  small  enough  so  their  contents  can  be  reduced  into 
the  abdomen  and  a  closure  of  the  abdomen  effected. 

Oldhausens  method  of  operation  is  effective  in  small  protrusions  of 
this  type.  It  consists  of  separation  of  the  skin  around  the  sac,  the 
removal  of  Wharton  jelly,  reduction  of  the  hernia  en  masse  without 
opening  the  sac,  and  suture  of  the  skin. 

Coley  has  treated  two  cases  of  small  size 
successfully  by  carefully  cleansing  the  parts, 
keeping  them  as  nearly  aseptic  as  possible, 
and  applying  pressure  to  the  hernial  tumor 
by  means  of  straps  of  adhesive  plaster  en- 
circling the  entire  abdomen. 

Infantile  Umbilical  Hernia. — This  variety  is 
most  common  during  the  first  year  of  life.  It 
is,  in  reality,  a  simple  yielding  of  the  umbilical 
cicatrix,  due    to  incomplete  closure  of    the 


Fig.  460. — Umbilical  hernia 
in  a  rachitic  negro  boy.  (Ash- 
hurst.) 


Fig.  461. — Adult  umbilical  hernia. 
(Roberts.) 


mesoblastic  layer.  This  type  is  small  in  size,  varying  from  1  to  3  c.c. 
in  diameter.  Many  disappear  spontaneously.  They  are  practically 
always  reducible  and  strangulation  is  exceedingly  rare  (Fig.  460). 

Treatment. — A  simple  pad  or  wooden  disk  covered  with  gauze  placed 
over  the  protrusion  and  held  securely  by  a  band  of  adhesive  plaster  is 
all  that  is  needed  to  effect  a  cure. 

Adult  Umbilical  Hernia. — This  is  the  most  important  variety  of 
umbilical  hernia.  It  occurs  generally  in  women,  most  frequently 
after  several  pregnancies.  It  may  exist  with  or  without  diastases  of 
the  recti,  usually  there  is  more  or  less  well-marked  separation  of  the 


936  HERNIA 

recti.  The  site  of  the  protrusion  is  most  commonly  just  above  the 
umbilicus,  although  it  may  occur  below  it.  The  tumor  is  generally 
made  up  of  a  sac  of  peritoneum,  which  may  or  may  not  be  covered 
with  a  fibrous  tunic  derived  from  the  rectus  sheath.  In  some  cases  the 
peritoneum  is  adherent  to  the  skin  and  both  may  become  so  atten- 
uated that  the  peristaltic  movement  of  the  contained  bowel  may 
be  distinctly  seen.  In  many  cases  inflammatory  adhesions  are  pres- 
ent between  the  bowel,  the  omentum  and  the  sac,  preventing  reduc- 
tion and  favoring  strangulation.  The  hernial  tumor  may  reach  an 
enormous  size  and  cause  great  disfigurement.  The  transverse  colon 
is  found  in  the  sac  more  commonly  than  any  other  part  of  the 
intestine. 

Symptoms. — In  the  early  stage  the  navel  appears  rounded  and  some- 
what bulging.  It  is  larger  in  circumference  than  usual,  and  a  distinct 
impulse  upon  coughing  is  felt.  At  first  there  is  a  slow  increase  in 
size,  more  rapidly  later,  especially  if  additional  pregnancies  follow, 
until  finally  it  may  assume  very  large  proportions  (Fig.  461). 

\Yhen  at  rest  such  a  hernia  appears  as  a  flaccid  abdominal  appendage, 
as  soon  as  the  abdominal  muscles  are  contracted,  the  tumor  becomes 
erect  and  tense.  In  these  cases,  more  or  less  pain  may  be  present, 
especially  on  severe  exertion.  There  is  in  addition  a  feeling  of  weakness 
and  lack  of  proper  support.  Digestive  disturbances  and  constipation 
are  frequent. 

The  size  of  the  hernia  is  often  an  inconvenience,  and  the  overlying 
skin  may  ulcerate  on  account  of  the  poor  nutrition.  Pain  from 
adhesions  and  attacks  of  local  peritonitis  are  not  uncommon.  The 
mortality  of  strangulated  gangrenous  umbilical  hernia  is  high,  being 
estimated  by  Gibson  as  67  per  cent.,  as  compared  with  inguinal  hernia, 
26  per  cent.,  and  femoral,  37  per  cent. 

Treatment. — When  the  protrusion  is  small  or  of  moderate  size  it 
may  be  treated  with  a  pad  and  adhesive  straps  or  with  a  truss.  The 
use  of  an  elastic  abdominal  belt  gives  great  comfort  in  the  more  severe 
cases  which  for  any  reason  are  not  suitable  for  operation. 

In  the  younger  women  where  the  protrusion  has  not  assumed  large 
proportions,  operation  should  be  performed  on  account  of  the  prob- 
able increase  in  size  with  its  attendant  discomfort  and  diminishing 
chance  for  a  complete  radical  cure.  Obese  women  in  middle  life  do 
not  stand  this  operation  well,  as  it  is  often  difficult  and  prolonged. 

There  is  a  mortality  of  5  per  cent,  in  irreducible  cases. 

The  simplest  operation  for  the  relief  of  the  ordinary  forms  of  ventral 
hernia,  whether  occurring  at  the  umbilicus  or  in  any  other  part  of  the 
abdominal  wall,  is  to  expose  the  sac,  empty  it  of  its  contents,  and  excise 
the  redundant  tissue.  Next  expose  the  various  layers  of  fascia,  muscle, 
and  aponeurosis,  and  unite  them  with  three  layers  of  sutures,  the 
first  of  catgut,  closing  the  peritoneum,  the  second  of  chromicized 
catgut,  uniting  the  freshened  muscular  and  aponeurotic  layers,  the 
third  of  silkworm  gut,  closing  the  cutaneous  wound. 


ANATOMICAL  VARIETIES  OF  HERNIA 


937 


If  union  takes  place  without  infection,  this  method  succeeds  in  the 
majority  of  instances  in  which  the  rupture  is  of  moderate  size.  In 
large  umbilical  hernia  and  those  due  to  an  extensive  diastasis  of  the 
rectus  muscles,  relapses  are  frequent  and  have  led  to  the  employment 
of  other  methods. 

Blake,  Mayo  and  a  number  of  other  surgeons  have  employed  suc- 
cessfully an  overlapping  of  the  abdominal  wall.  Blake's  description  of 
this  method  is  as  follows: 

"The  method  is  particularly  adapted  to  cases  with  diastasis  of  the 
recti  and  pendulous  abdominal  walls.  It  is  also  suitable  for  protru- 
sions elsewhere  in  the  linea  alba  than  at  the  umbilicus.  It  consists  in 
the  incision  of  a  large  elliptical  area  of  skin  and  fat  in  either  a  vertical 
or  a  transverse  direction,  down  to  and  exposing  on  one  side  at  least, 
very  completely,  the  sheaths  of  the 
recti.  In  typical  operations  the  in- 
cision has  included  an  area  from  25 
to  40  cm.  in  length  and  15  to  20  cm. 
in  breadth.  The  sac  is  partially  or 
wholly  excised  and  the  linea  alba  is 
divided  for  the  whole  length  of  the 
skin  incision.  The  peritoneum  is 
separated  if  possible  from  the  dorsal 
surface  of  one  rectus.  It  is  not 
necessarily  opened  except  at  the  her- 
nial sac.  One  musculo-aponeurotic 
wrall  is  then  drawn  over  the  other. 
The  amount  of  overlapping  varying 
from  4  to  10  cm.,  according  to  the 
laxity  of  the  abdominal  wall.  The 
margin  of  the  underlapped  side  is 
sutured  to  the  deep  surface  of  the 
overlapping  side  by  mattress  sutures 
of  chromicized  gut  which  are  tied  on 
the  superficial  surface  of  the  latter. 
The  margin  of  the  superficial  flap  is 

tacked,  with  interrupted  sutures  of  the  same  material  to  the  adjacent 
aponeurosis.  The  skin  wound  is  then  enclosed  without  drainage.  The 
results  of  this  method  in  the  hands  of  Blake  and  others  have  been 
excellent  (Fig.  462). 

Mayo  uses  a  transverse  incision  and  laps  the  upper  margin  down  over 
the  lower  margin  (Figs.  463  and  464).  This  method  has  the  advantage 
of  not  diminishing  the  capacity  of  the  abdomen  and  can  be  used  when 
the  abdominal  walls  are  not  relaxed,  while  the  method  of  lapping  from 
side  to  side  markedly  diminishes  the  capacity  of  the  abdomen  and  may 
seriously  incommode  respiration  leading  to  death  from  pneumonia  due 
to  non-aeration.  The  side-to-side  method  should  therefore  be  reserved 
for  cases  with  great  diastasis  and  lax  abdominal  walls. 


Fig.  462. — Blake's  operation  for  the 
radical  cure  of  umbilical  hernia. 


938 


HERNIA 


Ventral  Hernia. — Ventral  hernia  is  an  abdominal  protrusion  occur- 
ring at  some  point  other  than  the  navel  or  groin.    These  hernias  occur 


Fig.  463. — Suture  of  the  aponeurotic  and  peritoneal  structures,  sutures  placed.      (Mayo.) 


Fig.  464. — Sutured  aponeurotic  and  peritoneal  structures.     (Mayo.) 

more  frequently  from  the  yielding  scars  of  operative  wounds  (trau- 
matic ventral  hernia),  and  are  therefore  more  commonly  found  in 


ANATOMICAL    VARIETIES  OF  HERS  I A  939 

the  median  line,  over  the  appendix,  gall-bladder,  or  sigmoid,  or  in  the 
lumbar  regions.  Diastasis  of  the  recti  from  any  cause  above  or  below 
the  umbilicus  is  an  etiologic  factor  second  in  point  of  frequency. 
Small  fatty  hernias  of  the  linea  alba  above  the  navel  may,  by  drag- 
ging on  the  peritoneum,  give  rise  to  secondary  visceral  hernias  in  this 
region. 

The  great  majority  of  these  ruptures  are  similar  in  character  and 
general  behavior  to  the  adult  umbilical  hernias  just  described.  In  a 
small  number  of  cases  which  follow  abdominal  wounds  and  which 
have  healed  by  granulation,  only  a  thin  layer  of  skin  or  scar  tissue 
covers  the  protruding  viscera.  These  rarely  become  strangulated  on 
account  of  the  extensive  adhesions  which  are  generally  present. 

Diagnosis. — This  presents  no  difficulty  in  the  majority  of  cases 
and  can  be  made  by  inspection  and  palpation,  the  usual  features  of  a 
hernia  being  present  in  all  but  one  variety,  the  small,  fatty  hernias 
of  the  linea  alba.  As  these  consist  usually  in  the  protrusion  of  a  small 
knuckle  of  fat  from  the  subserous  fatty  tissue  through  a  small  open- 
ing in  the  linea  alba,  the  only  symptom  may  be  a  painful  point  in 
the  median  line  and  the  presence  of  a  small,  tender  nodule.  There  is 
little  or  no  impulse  at  first  and  the  tumor  is  often  exceedingly  small. 
At  times  there  may  be  a  well-defined  sac  with  omental  or  intestinal 
contents.  In  some  of  this  group  of  cases  the  symptoms  are  out  of  all 
proportion  to  their  size  and  consist  in  some  instances  of  pain  and  gastro- 
intestinal disturbances,  diarrhea  being  a  not  infrequent  symptom. 

Moschowitz  believes  that  the  vast  majority  of  epigastric  hernias  are 
composed  of  properitoneal  fat  originally  enclosed  in  the  falciform 
ligament,  traversing  the  hiatus  in  the  transversalis  fascia  and  linea  alba 
in  company  with  one  of  the  perforating  bloodvessels  in  this  region. 

Treatment. — The  treatment  of  ventral  hernia  is  the  same  as  for  the 
umbilical  variety.  The  epigastric  variety  as  described  by  Moschowitz 
is  treated  by  him  as  follows: 

"A  small  vertical  incision  is  made  over  the  centre  of  the  so-called 
hernia ;  the  skin  and  subcutaneous  fat  are  divided  and  retracted,  thereby 
exposing  a  lump  of  fat.  Search  is  now  made  for  the  bloodvessel 
previously  mentioned.  Usually  it  is  found  upon  the  left  side  of  the 
protrusion  and  this  vessel  is  caught  and  ligated.  The  fat  is  now  teased 
apart  in  order  to  be  absolutely  certain  that  there  is  no  true  sac. 
The  shreds  of  fat  are  now  ligated  to  obviate  a  secondary  hemorrhage. 
The  ligatures  are  placed  close  to  the  bottom  of  the  hole  in  the  trans- 
versalis fascia.  The  stumps  are  now  pushed  back  into  the  hole,  and  the 
latter  closed  with  one  or  two  stitches.  Finally  the  skin  is  closed  in  the 
usual  manner. 

Hotchkiss  has  reported  a  case  of  strangulated  epigastric  hernia 
but  they  are  rare. 

Hernia  in  the  linea  semilunaris  is  extremely  rare,  only  about  23 
cases  being  reported  in  the  literature,  while  hernia  in  the  linea  trans- 
versa3 and  hernia  of  the  pelvic  outlet  are  still  more  uncommon. 


940  HERNIA 

Diaphragmatic  Hernia. — A  protrusion  of  the  intestine  may  rarely 
take  place  through  the  diaphragm  into  the  cavity  of  the  thorax.  The 
weak  areas  in  the  diaphragm  are  in  front,  between  the  chondral  and 
ensiform  fibres,  and  behind,  near  the  external  arcuate  ligaments. 

Congenital  malformations  and  traumata  may  also  give  rise  to 
diaphragmatic  openings,  through  which  a  hernia  may  protrude. 

Lumbar  Hernia. — A  rare  form  of  ventral  hernia  in  which  the  pro- 
trusion occurs  in  Petit's  triangle,  between  the  external  oblique  and 
the  latissimus  dorsi  muscle,  just  above  the  iliac  crest,  below  the 
twelfth  rib,  or  through  one  of  the  vascular  foramina  of  the  lumbar 
aponeurosis. 

Obturator  Hernia. — An  exceedingly  rare  hernial  protrusion  through 
the  obturator  membrane,  adjacent  to  the  vessel  and  nerves.  A  tumor 
or  fulness  appears  in  Scarpa's  triangle  well  to  the  inner  side  of  the 
femoral  vessels  and  pain  is  present  along  the  course  of  the  obturator 
nerve.  If  non-strangulated  it  may  be  approached  from  without  along 
the  border  of  the  adductor  longus  and  between  it  and  the  femoral  vein. 
When  strangulated  it  is  best  approached  by  the  abdominal  route. 

Hernia  of  the  Large  Intestine. — Each  of  the  various  parts  of  the  large 
intestine,  the  cecum,  ascending,  transverse,  descending  colon  and  the 
sigmoid  flexure,  may  participate  in  the  formation  of  a  hernia,  and  if 
the  mechanism  by  which  these  various  segments  come  to  share  in  the 
hernial  protrustion  is  not  fully  understood  an  operation  for  the  radical 
cure  of  such  a  hernia  may  be  beset  with  great  difficulty  for  the  operator, 
and  grave  danger  for  the  patient. 

Parts  of  the  large  intestine,  which  normally  have  a  free  mesentery 
find  their  way  not  infrequently  into  the  sac  of  a  hernia  and  their  treat- 
ment differs  in  no  way  from  that  of  other  portions  of  the  intestine  with 
a  free  mesentery. 

There  is,  however,  a  group  of  cases  in  which  one  has  to  deal  with  a 
protrusion  into  a  hernial  sac  of  either  the  descending  or  ascending  colon, 
which  is  but  partially  covered  with  peritoneum.  And  the  manner  in 
which  these  portions  of  the  large  intestine  present  themselves  in  a 
hernial  sac  is  frequently  such  that  they  cannot  be  reduced  with  the 
rest  of  the  sac  contents,  owing  to  the  fact  that  part  of  the  sac  is 
formed  by  the  uncovered  (by  peritoneum)  surface  of  the  gut. 

As  descriptive  of  the  means  by  which  this  type  of  hernia  is  acquired, 
the  French  have  applied  the  term  hemic  par  glissement,  commonly 
known  as  sliding  hernia.  It  should  be  noted  that  this  term  does  not 
apply  to  a  hernia  of  those  portions  of  the  large  intestine  provided  with 
a  free  mesentery. 

There  are  two  different  mechanisms  by  which  this  type  of  hernia 
may  be  brought  about: 

1.  A  "pulling"  mechanism. 

2.  A  "pushing"  mechanism. 

Both  of  these  methods  have  been  recently  described  by  Moschowitz, 
who  has  pointed  out  the  successive  steps  by  which  these  hernias  are 


ANATOMICAL   VARIETIES  OF  HERNIA 


941 


Fig.  465. — Sliding  hernia  of  descending 
colon  by  "pulling"  mechanism.  First 
stage.  (Moschowitz.)  A,  peritoneum; 
B,  transversalis  fascia;  C,  descending 
colon;  D,  internal  inguinal  ring. 


Fig.  466. — Sliding  hernia  of  descending 
colon  by  "pulling"  mechanism.  Second 
stage.  (Moschowitz.)  A,  peritoneum; 
B,  transversalis  fascia;  C,  descending 
colon;  D,  sac  of  hernia. 


Fig.  467. — Sliding  hernia  of  descending 
colon  by  "pulling"  mechanism.  Third 
stage.  (Moschowitz.)  A,  peritoneum; 
B,  transversalis  fascia;  C,  descending 
colon;  D,  sac  of  hernia. 


Fig.  468. — Sliding    hernia  of  (descending 
colon  by  "pulling"  mechanism. 


Fig.  469. — A,  afferent  loop;  B, 
afferent  loop;  C,  sac  of  hernia. 
(Moschowitz.) 


Fig.  470. — A,  sigmoid  flexure;  B,  descending 
colon;   C,  herniated  colon.  (Moschowitz.) 


942  HERNIA 

acquired.     Sliding  hernias  are  acquired  by  the  pulling  mechanism 
as  follows: 

1.  There  must  be  a  certain  amount  of  mobilization  of  the  ascend- 
ing or  descending  colon  due  to  a  loosening  of  their  underlying  tissues, 
which  permits  the  colon  to  move  more  freely  in  its  bed. 

2.  There  is  created  an  adjacent  inguinal  hernial  sac. 

3.  With  the  increase  in  the  size  of  the  hernial  sac  traction  is  exerted 
upon  the  now  movable  segment  of  large  intestine  which  is  drawn 
toward  the  hernial  opening. 

4.  With  a  continuation  of  the  traction  forces,  it  is  obvious  that  the 
gut  may  be  pulled  down  until  it  comes  to  form  part  of  the  posterior 
surface  of  the  sac  (Figs.  465,  466,  and  467). 

Sliding  hernias  are  acquired  by  the  "pushing"  mechanism  as  follows: 

1.  As  in  the  previous  mechanism  it  is  necessary  to  have  a  certain 
amount  of  mobilization  of  the  parts  under  consideration  due  to  a  loosen- 
ing of  their  underlying  aveolar  tissues  which  permit  the  colon  to  move 
more  freely  in  its  bed. 

2.  Abdominal  pressure  directed  at  first  dorsad  over  the  descending 
colon,  just  above  its  junction  with  the  sigmoid  or  over  the  ascending 
colon,  just  above  its  junction  with  the  cecum,  tends  to  approximate 
the  ventral  and  dorsal  walls  of  the  colon  and  if  the  force  is  then  con- 
tinued in  a  direction  caudad  and  mesad  toward  the  internal  inguinal 
ring,  the  segment  of  the  large  intestine  to  which  the  pressure  has 
been  applied  tends  to  approach  the  internal  ring,  and  if  the  force  is 
continuous  it  is  finally  pushed  out  behind  the  peritoneum  into  the 
inguinal  canal,  giving  a  true  sacless  hernia. 

The  treatment  of  these  hernias  begins  with  their  recognition.  Hotch- 
kiss  has  called  attention  to  the  fact  that  patients  with  a  sliding  hernia 
are  exceedingly  intolerant  of  the  pressure  of  a  truss. 

The  hernia  which  is  acquired  by  the  "  pulling"  mechanism  is  apt 
to  be  large,  while  those  which  exist  as  a  result  of  the  "pushing"  mechan- 
ism are  usually  small.  Blake  found  that  in  many  of  these  cases  the 
gut  was  loosely  attached  to  the  abdominal  wall,  and  could  be  pushed 
back  en  masse. 

Moschowitz  found  that  in  the  hernias  acquired  by  the  "pushing" 
mechanism,  it  was  usually  possible  to  push  them  back  with  a  little 
blunt  dissection,  not  into  the  peritoneal  cavity,  but  into  the  retro- 
peritoneal space  and  found  it  unnecessary  to  open  the  peritoneal  cavity 
except  to  verify  the  correctness  of  the  diagnosis. 

Both  Hotchkiss  and  Walton  have  devised  operations  to  facilitate 
the  reduction  of  a  sliding  hernia  and  to  effect  a  repair. 

Hotchkiss  has  found  the  following  procedure  successful  in  these 
cases : 

1.  The  sac  is  freed  from  the  cord  to  its  full  extent. 

2.  Sac  is  opened  anteriorly  and  its  reducible  contents  replaced 
within  the  abdomen  and  retained  there  with  pads. 

3.  The  incision  in  the  sac  is  then  prolonged  upward  to  the  internal 


ANATOMICAL   VARIETIES  OF  HERNIA  943 

ring  and  downward  to  the  lowermost  point  of  the  sac,  which  will 
permit  of  easy  eversion  of  the  sac. 

4.  Grasping  the  adherent  intestine  and  pulling  it  gently  forward, 
it  will  be  found  that  the  peritoneum  of  the  hernial  sac  will  become 
everted  in  such  a  manner  as  to  form  a  new  elongated  mesentery  for 
the  sigmoid  with  its  smooth  peritoneal  surface  turned  out  to  form 
its  free  surface  and  its  outer  or  non-peritoneal  surface  falling  in 
contact. 

5.  Suturing  the  edges  of  this  new  mesentery  together  permits  its 
elongation  to  an  extent  sufficient  to  allow  the  perfect  reduction  of 
previously  adherent  intestine  into  the  abdominal  cavity. 

6.  Suture  the  opening  into  the  abdominal  cavity  with  a  purse-string 
suture  introduced  from  within. 

7.  Then  proceed  w'ith  the  usual  repair.  Transplantation  of  the 
rectus  is  frequently  of  value  in  these  cases. 

Relapses  are  more  common  than  in  any  other  form  of  hernia. 


CHAPTER   XXXII. 
AMPUTATIONS. 

General  Considerations.  —  The  indications  for  amputation  are 
injuries,  inflammations,  neoplasms,  gangrene,  or  deformities  of  an 
extremity  which  either  immediately  menace  the  life  of  the  individual, 
or  would  result,  if  saved,  in  a  member  which  would  be  functionally  or 
cosmetically  inferior  to  a  mechanical  substitute.  In  gangrene,  ampu- 
tation is  performed  to  anticipate  the  natural  separation  of  the  dead 
from  the  living  tissues.  These  indications  vary  not  only  with  the 
surgical  condition,  but  also  with  the  constitution  of  the  patient  and 
the  situation  of  the  part  affected.  An  aged  or  debilitated  individual 
who  would  survive  the  removal  of  part  of  a  lower  extremity  might 
fail  to  repair  a  resected  joint  or  badly  infected  or  lacerated  wound; 
and  an  injury  which  in  the  lower  extremity  demands  amputation, 
should  often,  in  the  upper,  be  treated  conservatively.  The  operation  is 
almost  without  exception  one  of  last  resort  and  should  be  undertaken 
only  when  failure  is  the  only  promise  from  any  other  method. 

The  time  for  amputating  is  of  especial  importance  in  severe  injuries, 
where  there  occur  four  distinct  periods:  First,  immediately  after 
the  injury;  second,  from  four  to  six  hours  afterward,  when  there 
has  been  partial  recovery  from  the  primary  shock;  third,  an  inter- 
mediary period  lasting  several  days  or  weeks  during  which  there  is 
active  inflammation;  and  fourth,  after  the  acute  inflammation  has 
subsided  and  the  dead  portions  sloughed  away. 

Of  these  periods  the  second  is  the  best  if  the  limb  is  hopelessly  in- 
jured, and  the  fourth  if  an  unsuccessful  attempt  has  been  made  to 
save  it.  Operation  in  the  first  stage  adds  to  an  already  severe  shock 
and  in  the  third  aids  in  the  spreading  of  a  very  active  inflammation 
in  a  weakened  host.  In  the  other  conditions,  being  a  procedure  only 
of  the  last  resort,  the  time  for  operation  depends  on  the  urgency  of 
the  pathological  condition  and  the  general  condition  of  the  patient. 

The  site  of  amputation  should  be  as  far  as  possible  from  the  trunk 
because  of  the  lessened  shock.  It  should  be  where  the  flaps  will  be 
well  supplied  with  blood;  a  level  often,  especially  in  cases  of  gangrene, 
at  some  distance  from  the  apparent  disease,  as  illustrated  by  amputa- 
tion through  the  thigh  for  gangrene  of  a  toe.  This  level  is  found  by  the 
Moschowitz  test  which  carefully  presses  the  blood  out  of  the  extremity 
by  means  of  an  Esmarch  bandage  and  leaves  a  tourniquet  at  the  base 
of  the  extremity  for  five  minutes  while  the  Esmarch  is  being  removed. 
The  tourniquet  is  then  suddenly  removed  and  the  blood  allowed  to 
flow  back  into  the  limb.  As  this  occurs,  a  pink  flush  will  advance 
down  the  extremitv  reaching;  the  toe  in  about  two  minutes.    In  vas- 


HEMOSTASIS  945 

cular  diseases,  this  pinkish  wave  will  be  arrested  at  some  level,  form- 
ing a  line  of  demarcation  below  which  the  skin  appears  bloodless  for 
several  minutes.  The  line  marks  the  limit  of  good  capillary  circulation 
and  the  line  of  amputation  should  be  safely  above  it. 

The  second  consideration  is  to  provide  a  serviceable  stump  to  which 
an  artificial  limb  can  be  readily  fitted,  as  in  the  tapering  portions  of 
the  thigh  and  leg,  instead  of  through  the  knee-joint  where  the  bulg- 
ing condyles  not  only  interfere  with  the  circulation  but  make  an 
uneven  surface  for  fitting  the  prothesis.  For  the  same  reason,  if  pos- 
sible, amputation  of  the  leg  should  be  between  a  level  of  20  cm.  from 
the  ground  and  10  cm.  below  the  tubercle  of  the  tibia.  In  the  upper 
extremity,  the  longer  the  remaining  stump  the  better. 

Preparation  for  Operation. — The  general  preparation  should  be  for 
a  severe  surgical  procedure;  maintenance  of  strength  up  to  the  day 
of  operation,  the  drinking  of  considerable  water  and  a  mild  cathartic 
the  day  before  operation.  The  local  preparation  should  follow  abso- 
lute aseptic  rules  where  it  is  possible,  care  being  taken  to  isolate  infected 
areas  from  those  which  can  be  made  sterile.  This  should  be  brought 
about  with  the  least  possible  addition  to  an  already  severe  shock, 


Fig.  471. — Author's  solid  rubber  tourniquet  with  metal  clasp. 

and  in  desperate  cases,  a  long-drawn-out,  uncertain,  antiseptic  prepara- 
tion of  an  already  infected  extremity  should  not  be  allowed  to  increase 
the  danger  of  immediate  postoperative  mortality. 

The  choice  of  anesthetic  is  that  for  a  procedure  in  which  the  element 
of  shock  is  greater  than  any  other  involving  the  same  amount  of 
tissue  handling.  It  is  best  to  give  a  preliminary  injection  of  \  gr.  of 
morphine  and  yws  gr.  of  atropine  one  hour  before  operation.  Com- 
bined general  and  local  anesthesia  is  used  wThere  possible  during  the 
operation,  the  local  anesthetic  being  directed  both  to  the  main  nerve 
trunk  and  also  to  the  subcutaneous  tissues  where  this  procedure  does 
not  delay  healing.  Spinal  anesthesia  may  be  indicated  in  the  aged 
or  those  suffering  from  pulmonary  disease. 

Hemostasis. — In  all  the  major  amputations  it  is  desirable  to  prevent 
unnecessary  loss  of  blood  during  the  operation  by  the  application 
of  a  tourniquet  to  the  limb,  well  above  the  operative  field,  in  such  a 
position  that  it  will  compress  the  main  arterial  trunk.  For  this  pur- 
pose the  old-fashioned  Petit's  tourniquet  may  be  employed,  or  simply 
a  firm  India-rubber  tube  drawn  tightly  about  the  limb  and  tied  or 
held  with  forceps.  The  author's  solid  rubber  tourniquet  with  metal 
clasp  is  perhaps  the  easiest  to  apply  and  to  loosen  (Fig.  471). 
60 


946  AMPUTATIONS 

Other  methods  are:  digital  compression  of  the  main  arterial  trunks, 
compression  of  the  base  of  a  flap,  immediately  as  it  is  cut,  by  the  grasp 
of  the  hand  or  an  elastic  ligature,  and  by  clamping  and  ligating  the 
vessels  as  found  in  the  dissection. 

Bloodless  amputations  can  be  secured  by  the  application  of  the 
Esmarch  rubber  bandage  from  the  extremity  of  the  limb  to  the  point 
of  application  of  the  tourniquet.  To  be  effective,  the  limb  should  be 
blanched  and  remain  so  until  the  tourniquet  is  removed.  The  disad- 
vantages of  this  method  are:  the  reactionary  congestion  of  the  limb, 
which  occurs  after  the  tourniquet  is  removed,  and  leads  to  trouble- 
some oozing  and  the  necessity  for  many  ligatures,  and  the  permanent 
loss  of  capillary  circulation  in  individual  suffering  from  endarteritis. 

The  Handling  of  Tissues  During  an  Amputation. — Skin  and  sub- 
cutaneous tissues  should  be  handled  gently,  because  it  is  the  most 
important  structure  for  the  healing  of  a  flap,  and  easily  injured  on 
account  of  the  imperfect  support  offered  by  the  fat  to  its  bloodvessels. 
In  dissecting  skin  and  subcutaneous  tissues,  the  knife  should  be  directed 
toward  the  muscles  and  never  toward  the  skin,  and  the  muscular  fascia 
sacrificed  rather  than  injure  the  subcutaneous  tissue. 

Muscles  and  tendons  should  be  sutured  together  over  the  end  of  the 
cut  bone,  to  diminish  atrophy  of  the  stump  by  maintained  muscular 
activity,  to  aid  in  the  movement  of  the  stump,  and  to  protect  the  end 
of  the  stump  from  trauma.  In  planning  the  muscular  portion  of  the 
flap  allowance  must  be  made  for  the  difference  in  the  contracting 
power  of  antagonistic  groups,  including  in  the  longer  flap  the  least 
powerful  group,  so  that  the  muscular  scar  will  be  in  the  same  position 
as  the  cutaneous,  and  drawn  upward  away  from  the  end  of  the  bone. 
Important  muscular  attachments  such  as  the  supinator  longus  in  the 
wrist,  the  pronator  radii  teres  in  the  forearm  and  the  patellar  tendon 
should  remain  undisturbed. 

Improper  handling  of  bone  and  periosteum  is  the  source  of  a  large 
percentage  of  painful  stumps  because  of  the  growth  of  osteophytes 
of  various  sizes  and  sharpness,  from  spicules  of  bone  and  shreds  of 
periosteum  which  form  bony  masses  gripping  the  sensory  nerve  fibres 
and  passing  directly  to  the  overlying  skin.  This  difficulty  is  avoided 
by  simple,  clean  treatment  of  periosteum  and  bone,  the  former  by  a 
sharp  knife  and  the  latter  in  the  same  groove  by  a  fine-toothed  saw. 

More  elaborate  methods  preventing  these  growths  may  be  employed, 
as  Bier's  method,  in  which  bone  is  made  to  cover  the  end  of  the  cut 
surface  of  the  stump. 

Bunge  attempts  to  accomplish  the  same  result  by  destruction  of  all 
osteogenetic  tissue  near  the  cut  end  of  the  bone :  first,  by  an  absolutely 
clean  removal  of  periosteum  for  3  mm.  above  the  cut  edge  of  the 
bone;  and  second,  by  the  same  treatment  of  the  endosteum  and 
marrow.  The  results  of  the  latter  treatment  are  apparently  as  good 
as  those  of  the  osteoplastic  procedure,  and  in  cases  where  time  is 
valuable,  is  the  method  to  be  preferred. 


METHODS  OF  MAKING  THE  FLAPS 


947 


The  main  arterial  trunks  with  their  veins  are  found  in  their 
anatomical  positions,  and  are  doubly  ligated  after  being  cleanly 
dissected.  The  secondary  branches  are  sought  in  the  intermuscular 
septa,  clamped  and  ligated  as  are  any  visible  vessels  in  any  of  the 
muscles  or  subcutaneous  tissues.  The  tourniquet  is  removed  after 
such  ligation,  and  any  remaining  bleeding  points  caught  and  ligated 
as  found.  If  the  condition  of  the  patient  warrants  it,  the  wound  is 
watched  for  about  ten  minutes  to  catch  those  bloodvessels  which 
bleed  during  the  secondary  congestion  following  the  application  of 
an  Esmarch.  In  a  clean  case  this  will  diminish  oozing  and  con- 
siderably hasten  the  process  of  repair. 

As  far  as  possible  the  main  nerve  trunks  are  found  and  secured  before 
severing  the  bloodvessels  which  accompany  them.  They  are  cleanly 
dissected  and  pulled  downward  from  4  to  8  cm.,  are  anesthetized, 


Fig.  472. — Kinetic  stump. 


and  cut  with  a  sharp  knife,  thus  permitting  retraction  above  the 
end  of  the  stump  or  from  any  area  which  would  be  pressed  upon 
by  a  scar.  Whenever  a  nerve  is  cleanly  cut  there  forms  a  so-called 
neurofibroma.  If  this  structure  lies  loose  in  the  soft  tissues  it  causes 
no  symptoms,  but  if  caught  in  the  bony  scar  tissue,  causes  great  pain. 

Drainage  is  eliminated  as  far  as  possible,  but  it  should  be  employed 
in  infected  or  doubtful  cases  rather  than  risk  the  danger  of  cellulitis 
and  osteomyelitis. 

Kinetic  stumps  are  formed  by  making  loops  of  skin-covered  muscles 
or  tendons  to  which  cords  may  be  attached  and  connected  with  various 
parts  of  an  artificial  limb — with  a  view  to  securing  a  certain  amount 
of  voluntary  motion  in  the  prosthetic  apparatus  (Fig.  472). 

Methods  of  Making  the  Flaps. — Flaps  are  made  of  skin,  which  should 
always  include  the  subcutaneous  areolar  tissue ;  of  skin  and  muscle ;  of 


948 


AMPUTATIONS 


'I 


skin,  muscle,  and  periosteum;  or  the  flap  may  contain  also  a  portion 

of  adherent  bone  (osteoplastic  amputations). 

Skin  flaps  are  made  by  cutting  from  without 
inward  with  a  large  scalpel.  The  flap  is  generally 
first  marked  out,  and  should  be  as  broad  at  the 
extremity  as  at  the  base ;  otherwise  the  normal  re- 
traction of  the  tissue  will  result  in  the  formation  of 
a  conical  flap  which  can  be  made  to  cover  the 
muscular  and  bony  stump  only  with  difficulty. 
In  raising  the  flap  the  blade  of  the  scalpel  should 
be  directed  toward  the  muscle,  to  insure  freedom 
from  injury  of  the  subcutaneous  vessels.  When  the 
flap  is  to  be  composed  of  skin  and  muscle,  it  can 
be  made  by  transfixion,  or  by  the  method  of  skin 
dissection  from  without,  as  just  described. 

In  the  method  of  transfixion  the  left  hand  of 
the  operator  grasps  and  raises  the  fleshy  part  of 
the  limb  above  the  bone.  A  long-bladed  amputat- 
ing-knife  (Fig.  473)  is  then  passed  transversely 
through  the  limb  above  the  bone,  and  by  a  sawing 
motion  an  oval  flap  is  made,  the  apex  of  which  is 
directed  downward.  The  knife  is  then  reintroduced 
below  the  bone  and  a  similar  flap  cut  from  the 
inferior  aspect  of  the  limb.  These  are  then  re- 
tracted, the  bone  sawed  through,  and  the  distal 
portion  removed.  If  the  flap  is  made  by  cutting 
from  without,  the  skin  is  first  incised  and  dissected 
backward  for  about  an  inch,  the  muscles  are  then 
divided  down  to  the  bone  on  either  side,  and 
separated  from  it  by  blunt  dissection;  or,  after  the 
skin  is  retracted,  the  muscles  may  be  divided  by 
transfixion,  care  being  taken  to  insure  the  muscular 
part  of  the  flap  being  smaller  in  extent  than  its 
cutaneous  covering. 

If  the  flap  is  to  contain  periosteum,  it  should  be 
separated  from  the  bone,  but  not  from  the  muscle, 
and  should  be  of  such  a  shape  that  it  will  fall  over 
and  cover  the  cut  extremity  of  the  shaft  when  the 
flaps  are  sutured  in  place.  Periosteal  flaps,  unless 
made  in  this  manner,  are  worse  than  useless,  because 
they  generally  leave  a  portion  of  the  bone  exposed, 
and  therefore  favor  necrosis.  It  is  better  to  follow 
the  advice  of  Bryant,  and  saw  the  bone  without 
disturbing  the  periosteum. 
In  osteoplastic  amputations  the  object  is  to  cover  the  open  extremity 

of  the  shaft  by  a  thin  section  cut  from  a  neighboring  bone,  which 

retains  its  connection  with  one  of  the  flaps.    The  results  of  this  opera- 


Fig.  473.  —  Long- 
bladed  amputating- 
knife. 


SKIN-FLAP  METHOD  949 

tion  at  the  ankle  and  at  the  knee-joint  have  been  so  satisfactory  that 
Bier  and  others  have  sought  to  apply  it  to  amputations  in  other 
localities;  and  while  it  undoubtedly  gives  a  better  bearing  stump 
when  the  plan  can  be  successfully  carried  out,  the  technical  difficulties 
in  situations  in  which  the  protecting  bone  flap  has  to  be  sawed  from 
the  shaft  of  a  long  bone  are  so  great  that  the  procedure  has  not  as  yet 
been  generally  adopted. 

The  Circular  Method. — This  method  is  chiefly  applicable  to  the  thigh 
and  arm,  but  it  may  be  used  also  in  the  leg  and  forearm.  It  is  carried 
out  in  the  following  manner:  A  circular  incision  is  made  through  the 
skin  and  subcutaneous  tissue  at  a  distance  not  less  than  one-fourth  of 
the  circumference  of  the  limb,  from  the  point  of  division  of  the  bone 
(Bryant).  This  is  made  best  by  a  long-bladed  amputating-knife, 
and  the  integument  dissected  from  the  deep  fascia  and  muscles  and 
turned  upward  as  a  cuff.  An  assistant  then  draws  the  tissues  well 
upward,  and  the  surgeon  makes  a  second  circular  incision  around  the 
limb,  this  time  dividing  the  superficial  layer  of  muscles.  A  third 
section  is  then  made,  after  further  re- 
traction of  the  soft  parts  by  the  assistant, 
dividing  the  deeper  muscular  layer  to 
the  bone.  The  soft  parts  are  then  drawn 
well  away  from  the  bone  by  a  two- 
tailed  muslin  retractor,  and  the  bone 
sawed  through  and  the  sharp  edges 
rounded  off  by  the  rongeur.  This 
leaves  a  funnel-shaped  hood  of  soft  tis- 
sue, which  falls  over  the  bone,  and  may  Fig.  474.— Amputation  through 
be  united  with  a  few  deep  catgut  sutures  fZh'T"  *  ^^  ""*"* 
for  the  skin  (Fig.  474). 

Several  modifications  of  this  method  are  in  use — one  in  which 
the  muscles  are  divided  by  a  single  cut  at  the  base  of  a  long  cutaneous 
cuff,  another  in  which  one  or  more  vertical  incisions  are  made  in  the 
skin  flap  with  more  or  less  rounding  of  the  edges  (Liston). 

Skin-flap  Method. — In  this  method  two  equal  or  unequal  flaps  are 
made  of  skin  and  fascia.  These  may  be  an  anterior  and  a  posterior 
one;  or  two  lateral  flaps,  each  of  which  should  be  rectangular  in 
shape,  with  the  distal  corners  rounded.  In  cutting  these  flaps,  one 
should  estimate  the  combined  length  to  be  not  less  than  one  and 
a  half,  and  often  two,  diameters  of  the  limb  at  the  point  of  bone  section. 
The  flaps  are  dissected  free  from  the  muscles  and  retracted,  after 
which  the  muscles  may  be  divided  to  the  bone  by  a  circular  incision 
at  the  base  of  the  skin  flaps  (Fig.  475).  In  case  it  happens  that  the 
injury  or  disease  for  which  the  amputation  is  undertaken  is  situated 
on  one  side  only  of  the  limb,  practically  the  entire  flap  may  be  raised 
from  the  opposite  side.  Care  should  always  be  taken,  however,  in 
these  cases  to  include  the  deep  fascia  in  the  flap,  on  account  of  the 
increased  blood  supply  thus  obtained. 


950 


AMPUTATIONS 


Skin-  and  Muscle-flap  Method. — In  this  method  two  flaps  are  made, 
consisting  of  skin  and  muscle.  These  may  he  of  equal  or  unequal 
length,  and  are  generally  made  by  transfixion  from  within  outward, 
or  by  dissecting  them  from  without  inward  as  described  above. 

It  is  a  quick  and  easy  method,  and  is  chiefly  applicable  to  the  thigh, 
arm,  or  fleshy  part  of  the  forearm  or  leg.    After  the  flaps  are  cut  they 


. — — — . 


Fig.  475.- 


-Modified  circular  amputation:  skin  flaps  and  circular  incision  through 
muscles.     (Esmarch.) 


should  be  retracted  with  a  two-  or  three-tailed  muslin  retractor  and 
the  bones  sawed,  after  which  the  muscles  should  be  brought  together 
with  several  buried  sutures  of  heavy  catgut,  and  the  skin  united  in 
the  usual  manner. 

Lateral  skin  and  muscle  flaps,  so  fashioned  that  the  incision  reaches 
a  higher  point  behind  than  in  front,  are  advocated  by  Stephen  Smith 


Fig.  476. — Amputation  by  Teale's  method. 


and  others  on  the  ground  of  better  drainage  and  the  fact  that  retraction 
of  the  scar  eventually  brings  the  cicatrix  behind  and  out  of  the  way 
of  pressure  by  an  artificial  limb. 

Teale's  Method. — This  method  is  applicable  chiefly  to  the  leg  and 
forearm,  and  should  consist  in  a  long  anterior  flap  of  skin  and  muscle, 
and  a  short  posterior  flap  similarly  constructed.     The  length  of  the 


POSTOPERATIVE  TREATMENT  951 

anterior  flap  should  be  one-hall  the  circumference  of  the  limb  at 
the  point  of  bone  section;  that  of  the  posterior,  one-quarter.  Kadi 
flap  should  be  rectangular,  and  should  include  all  the  tissues  down 

to  the  hone.  After  section  of  the  bones  the  anterior  flap  should  be 
folded  over  the  hones  and  stitched  to  the  posterior  flap  (Fig.  476). 
The  advantages  of  the  method  are  that  it  affords  good  drainage  and 
furnishes  a  serviceable  stump.  The  principal  disadvantage  is  that  it 
requires  a  high  division  of  the  bone,  and  therefore  involves  a  greater 
sacrifice  of  the  limb  than  other  methods. 

The  Racket-shaped  Method. — This  method  is  a  modification  of  the 
circular  method,  and  consists  in  an  oval  or  circular  skin  incision 
extending  around  the  limb  which  is  joined  by  a  perpendicular  incision 
extending  for  a  variable  distance  upward,  along  the  bone.  It  is 
applicable  to  the  fingers  and  toes,  especially  when  the  amputation 
is  performed  at  the  base  of  the  digit. 

A  similar  incision  is  also  extensively  employed  at  the  hip-  and 
shoulder-joints,  but  in  these  regions  the  flaps  are  made  of  skin  and 
muscle. 

Postoperative  Treatment. — Immediately  after  operation  attempts 
should  be  made  to  prevent  pressure  of  the  bone  end  against  the  soft 
tissues  of  the  flap.  This  can  be  accomplished  by  binding  the  limb  to  a 
splint  which  holds  the  tissues  well  down  over  the  end  of  the  bone  or  by 
making  direct  traction  with  adhesive  plaster  on  the  soft  parts  so  that 
any  retraction  of  the  muscles  is  overcome.  As  soon  as  the  wound  is 
solid,  vigorous  attempts  are  made  to  increase  the  mobility  of  the  stump 
and  to  diminish  its  abnormal  sensibility.  This  is  accomplished  by 
massage  or  even  rough  handling,  as  by  blows  of  moderate  severity, 
by  hot  and  cold  baths,  and  bandaging.  As  soon  as  all  sensitiveness 
has  left  the  end  of  the  bone  an  artificial  limb  should  be  fitted  and 
the  patient  urged  to  make  early  efforts  to  use  the  extremity.  Delay 
in  this  is  often  a  serious  mistake  for  the  reason  that  the  patients 
become  used  to  crutches  and  are  therefore  unwilling  to  endure  dis- 
comfort and  pain  which  always  accompany  the  early  efforts  to  use  an 
artificial  leg. 

Conical  stumps  occur  when  flaps  have  been  too  short  or  where 
there  has  been  growth  of  bone  after  amputation.  The  result  is  that 
the  bone  end  pushes  down  the  skin  covering  it  into  a  rounded  cone 
which  often  is  highly  sensitive  and  prevents  the  use  of  an  artificial 
limb.  The  treatment  is  to  reamputate  with  flaps  cut  to  the  proper 
length. 

Painful  stumps  also  are  caused  by  nerves  being  caught  in  a  rigid 
scar,  by  the  formation  of  osteophytes  from  ragged  bone  and  periosteum, 
and  from  fixation  <^f  the  scar  over  the  bone  end. 

Treatment  is  preventive  by  proper  operative  technic.  Curative 
methods  are  to  sever  the  nerve  trunks  at  a  higher  level,  to  cleanly 
remove  the  rough  ends  of  bone,  and  to  interpose  fat  or  aponeurosis 
between  the  bone  end  and  the  skin. 


952  AMPUTATIONS 

The  Use  of  Artificial  Limbs. — With  a  view  to  determining  the  con- 
ditions which  favor  the  successful  use  of  an  artificial  limb  after  ampu- 
tation of  the  lower  extremity,  Dr.  F.  T.  Murphy  addressed  a  circular 
letter  to  500  patients  treated  at  the  Massachusetts  General  Hospital 
from  1888  to  1892.  He  also  made  inquiries  of  eleven  well-known 
firms  manufacturing  artificial  limbs.  From  the  replies  he  received, 
he  concludes  that  a  serviceable  weight-bearing  stump  is  best  secured 
by  covering  the  end  of  the  bone  by  a  layer  of  muscle  rather  than  by  a 
simple  skin  flap;  that  a  periosteal  covering  of  the  end  of  a  bone  is 
desirable;  that  in  leg  amputations  the  fibula  should  be  cut  at  a  higher 
level  than  the  tibia ;  that  the  sharp  subcutaneous  tibial  edge  should  be 
removed,  and  that  every  effort  should  be  made  to  avoid  wound  infec- 
tion. He  also  found  that,  as  a  rule,  all  partial  amputations  of  the  foot 
and  most  amputations  at  the  ankle  were  unsatisfactory,  but  that  a 
tibial  stump  between  6  and  8  inches  in  length  is  to  be  preferred,  as  it 
gave  to  the  patient  an  increased  sense  of  security,  far  more  comfort, 
and  a  greater  degree  of  strength  in  the  subsequent  use  of  his  artificial 
limb.  Amputations  at  the  knee-joint  are  inferior  to  those  just  above 
the  condyles. 

In  general  it  was  found,  as  a  result  of  these  investigations,  that  if 
we  aim  to  secure  the  greatest  comfort  in  the  use  of  an  artificial  extrem- 
ity, we  should  avoid  joint  amputations,  provide  adequate  muscular 
covering  for  the  end  of  the  bone,  and  make  every  effort  to  secure 
primary  union. 

The  use  of  kinetic  stumps  of  the  upper  extremity  has  opened  a  wide 
field  for  mechanical  ingenuity. 

SPECIAL  AMPUTATIONS. 

Amputations  of  the  Fingers. — It  should  be  remembered  that  on  the 
dorsal  aspect  of  the  fingers  the  joint  lies  below  the  knuckle,  which  is 
formed  by  the  inferior  extremity  of  the  bone  alone.  The  distal  joint 
lies  one-twelfth  of  an  inch  below  its  bony  prominence,  the  interphalan- 
geal  joint  one-sixth  of  an  inch,  and  the  metacarpophalangeal  joint 
one-third  of  an  inch  below  the  knuckle  (Jacobson).  The  creases  on 
the  palmar  aspect  practically  correspond  to  the  joint  line  for  the 
distal  joints;  the  upper  one  lies  about  three-quarters  of  an  inch  below 
the  metacarpophalangeal  joint  (Fig.  477). 

In  amputations  through  the  phalangeal  joints  the  method  by  the 
long  palmar  flap  is  to  be  preferred,  for  the  reason  that  the  flap  is  thicker, 
better  nourished,  possesses  greater  sensibility,  and  the  scar  is  above 
and  out  of  the  way.  The  extremity  of  the  finger  should  be  firmly 
grasped  and  partly  flexed.  A  long,  thin-bladed  knife  should  then 
incise  the  skin  immediately  over  the  joint  line,  enter  the  joint,  and 
then  pass  beneath  the  head  of  the  distal  phalanx,  and  by  one  or  two 
sawing  movements  cut  a  long  palmar  flap.  This  is  turned  up  and 
united  to  the  edge  of  the  dorsal  incision  by  three  or  four  sutures  of 


SPECIAL  AMPUTATIONS 


953 


silk  or  silkworm  gut.     Occasionally  one  or  two  small  vessels  may  need 
ligation    (Fig.   47S).     In   amputations   at  the   interphalangeal   joint 


Fig.  477.— Racket-shaped   incision  for  amputation   of   the   finger  at  the   metacarpo- 
phalangeal joint.     (After  Rotter.) 

Tiffany  recommends  including  the  tendon  and  its  sheath  in  the  sutures 
to  insure  good  voluntary  movement  of  the  stump. 


Fig.  478. — Amputation  of  a  finger  by  the  long  palmar  flap.     (After  Esmarch.) 

In  amputations  between  the  joints  the  double  skin  flap  may  be 
employed,  either  anteroposterior  or  lateral.  If  the  former  is  employed, 
the  palmar  should  be  the  longer,  for  reasons  already  given.    In  metacar- 


954  AMPUTATIONS 

pophalangeal  amputations,  the  lateral  flap  in  the  index  and  little  finger, 
and  in  the  other  fingers,  the  racket-shaped  incision  should  he  employed. 
Amputations  at  the  distal  joint  of  the  thumb  should  be  by  the  palmar 
flap;  at  the  metacarpophalangeal  or  carpometacarpal  joints,  by  the 
racket  incision. 

In  traumata  of  the  hand  it  must  be  remembered  that  fingers  or 
parts  of  fingers  may  often  be  saved  even  after  severe  lacerations  and 
compound  fractures,  and  that  an  effort  should  always  be  made  to  retain 
as  much  of  the  thumb  as  possible.  It  should  also  be  remembered  that 
an  immovable  stump  of  a  finger  is  worse  than  useless.  In  many  cases 
atypical  amputations  are  possible,  and  irregular  but  viable  strips 
of  tissue  often  can  be  employed  to  cover  bone  and  fill  up  gaps  in  the  soft 
parts. 

Amputation  at  the  Wrists. — Amputations  at  the  wrist  may  be  accom- 
plished by  the  double-flap  method,  by  the  long  palmar  flap,  or  by  the 
external  flap;  in  the  latter  case  the  flap  is  taken  from  the  external 
surface  of  the  thumb  as  high  as  the  metacarpophalangeal  joint  (Dub- 
reuil).  Of  these,  the  palmar  flap  method  is  to  be  preferred.  In  this 
an  incision  is  made  from  one  styloid  process  downward  on  the  palm 
of  the  hand  to  a  point  opposite  the  middle  of  the  metacarpal  bone,  then 
transversely  to  the  opposite  side  and  downward  to  the  other  styloid, 
making  a  rectangular  flap  with  rounded  edges.  The  flap  consists  of 
skin,  subcutaneous  fat,  and  a  small  portion  of  the  muscle  from  the 
thenar  and  hypothenar  eminences.  The  two  extremities  of  this 
incision  are  joined  by  a  transverse  dorsal  incision.  The  joint  is 
then  opened  from  the  dorsal  side  and  the  disarticulation  completed  by 
division  of  the  ligaments  and  tendons,  the  palmar  flap  turned  upward 
and  united  to  the  edge  of  the  dorsal  incision.  The  attachment  of  the 
supinator  longus  is  carefully  preserved. 

Amputation  of  the  Forearm. — Amputation  of  the  forearm  is  usually 
accomplished  by  the  double-flap  method.  In  the  lower  portion  the 
flaps  should  be  of  skin  from  the  flexor  and  extensor  surfaces.  In  the 
upper  portion  the  muscles  may  be  included  in  the  flaps.  The  flaps 
may  be  equal  in  length,  but  the  long  dorsal  and  short  palmar  method 
is  to  be  recommended.  The  tendons  or  muscles  are  sutured  over  the 
ends  of  the  bones,  or  held  to  the  interosseous  membrane.  AYhen 
possible,  the  bones  should  be  divided  below  the  attachment  of  the 
pronator  radii  teres  muscle,  to  insure  pronation  and  supination  of  the 
stump,  an  important  factor  in  contributing  to  the  usefulness  of  an 
artificial  arm  and  hand. 

Amputation  at  the  Elbow-joint. — The  circular,  the  double-flap,  or 
the  long  anterior  or  posterior  flap  methods,  may  all  be  employed  in 
this  region.  Of  these,  the  long  anterior  flap,  consisting  of  skin  and 
muscle,  is  to  be  preferred.  This  is  made  either  by  transfixion  or  by 
cutting  from  without  inward,  and  is  joined  posteriorly  by  a  short 
flap  of  skin.  When  the  region  of  the  joint  is  exposed,  it  is  opened 
from  the  outer  side  and  disarticulation  effected  by  division  of  the 


SPECIAL  AMPUTATIONS  955 

ligaments  and  tendon  of  the  triceps  muscle.  The  fleshy  anterior 
flap  falls  over  the  condyles  and  is  attached  to  the  posterior  flap  by  a 
number  of  cutaneous  sutures.  It  is  especially  important  in  this 
amputation  that  the  flaps  be  sufficiently  long  to  avoid  tension  and  to 
suture  the  flexor  to  the  extensor  muscles,  otherwise  retraction  may  occur 
and  one  or  both  condyles  may  protrude. 

Amputation  of  the  Arm. — The  conditions  here  are  favorable  to  almost 
any  method  of  amputation.  The  circular  and  the  double-flap  methods 
are  the  ones  usually  employed ;  and  have  been  described  in  the  earlier 
part  of  the  chapter.  Here  it  is  that  kinetic  stumps  (see  above)  offer 
the  greatest  field. 

Amputation  at  the  Shoulder- joint. — Hemostasis  in  this  operation  is 
secured  best  by  a  preliminary  ligation  of  the  axillary  artery  in  its  upper 
third  or  by  digital  compression  of  the  subclavian.  The  use  of  the 
rubber  tourniquet  passed  beneath  the  arm  and  drawn  upward  and 
clamped  above  the  clavicle,  and  held  in  place  by  an  assistant  or  by 
means  of  the  Wyeth  pins,  introduced  one  through  the  anterior  and  one 


Fig.  479. — Amputation  flaps:     1,  circular;    2,  oblique;    3,  unilateral  Ions  flap;    4,  racket; 
5,  bilateral  with  square  ends;    6,  bilateral  with  round  ends  as  in  transfixion. 

through  the  posterior  fold  of  the  axilla,  each  emerging  one  inch  within 
the  tip  of  the  acromion,  is  a  satisfactory  method  in  thin  subjects. 

Two  methods  are  to  be  recommended  for  this  amputation :  the  deltoid 
flap  method  and  the  racket  incision. 

The  deltoid  method  consists  in  a  long  oval  skin  and  muscle  flap, 
including  the  greater  part  of  the  deltoid.  This  is  made  by  transfixion 
or  by  a  cut  from  without  inward  extending  from  the  coracoid  process 
downward  to  the  point  of  insertion  of  the  deltoid,  then  backward  and 
upward  to  the  root  of  the  acromion.  The  tissues  are  raised  from  the 
bone  and  retracted  well  upward.  The  internal  rotators  and  then  the 
external  are  severed  at  their  insertion,  the  capsule  is  incised,  the  other 
muscular  attachment  severed,  and  the  head  forced  upward  out  of  the 
socket.  The  blade  of  the  knife  is  then  passed  behind  the  head,  and  a 
short  posterior  flap  made  by  cutting  downward.  The  large  deltoid 
flap  is  trimmed  to  fit  the  opening  thus  made,  and  after  the  vessels  are 
secured  is  stitched  to  the  lower  margin  of  the  wound. 

The  racket-shaped  incision  is  the  one  generally  employed.  In  it 
the   perpendicular   portion   of   the   incision   is  to   be   made   from   a 


956 


AMPUTATIONS 


point  near  the  coracoid  process  (Spence)  (Fig.  480),  from  a  point 
between  this  and  the  acromion  (Farebeuf),  or  from  a  point  just  beneath 
the  acromion  on  the  outer  aspect  of  the  arm  (Larrey).     In  all  of  these 

the  perpendicular  incision  is  carried  down- 
ward to  a  point  opposite  the  attachment  of 
the  pectoralis  major  muscle  to  the  humerus. 
From  this  point  the  incision  is  carried  around 
the  arm  as  in  circular  amputation.  The 
vertical  arm  of  the  incision  is  next  carried 
to  the  bone  and  the  head  exposed  by  lateral 
retraction  of  the  two  flaps  thus  formed. 
The  capsule  is  divided,  the  muscular  at- 
tachment cut,  the  head  disarticulated, 
separated  from  the  remaining  soft  parts, 
and  the  arm  removed. 

Interscapuiothoracic  Amputation. — In  in- 
terscapulothoracic  amputation,  or  removal 
of  the  entire  shoulder-girdle,  an  incision  is 
made  from  the  sternoclavicular  junction 
along  the  clavicle  to  the  coracoid  process; 
from  this  point  the  incision  passes  down- 
ward to  the  junction  of  the  arm  with  the 
anterior  fold  of  the  axilla,  then  around,  beneath  the  arm,  to  the 
edge  of  the  latissimus  dorsi  muscle;  crossing  this  it  passes  downward 
to  the  angle  of   the   scapula,  then   upward    across  the  spine  of  the 


Fig.  470.  —  Disarticulation 
at  the  shoulder,  Spence's 
method.     (Stimson.) 


Fig.  4S1. — Amputation  of  the  arm,  scapula,  and  part  or  all  of  the  clavicle.  (The 
dotted  line  represents  the  part  of  the  incision  which  lies  on  the  posterior  aspect  of 
the  body.)     (Treves.) 

scapula  to  join  the  incision  over  the  clavicle  about  its  middle  (Fig. 
479).  The  incision  simply  includes  the  skin  and  subcutaneous 
areolar  tissue.     The  incision  over  the  clavicle  is  next  deepened,  the 


SPECIAL  AMPUTATIONS 


.957 


clavicle  disarticulated  from  the  sternum  and  carefully  raised  throughout 
its  entire  length.  The  attachment  of  the  pectoralis  minor  to  the 
coracoid  process  is  severed  and  the  brachial  plexus  and  axillary  vessels 
exposed.  The  vessels  are  double  ligated  and  divided,  and  the  nerve- 
trunks  anesthetized  by  novocaine  (4  per  cent.)  and  cut. 

The  remaining  portions  of  the  incision  are  then  deepened,  the 
scapula  fully  exposed,  its  muscular  attachments  divided,  and  the  entire 
upper  extremity  removed.  The  posterior  scapular  and  suprascapular 
arteries  should  be  clamped  and  ligated ;  also  a  number  of  other  smaller 
vessels.  The  two  flaps,  pectoro-axillary  and  the  cervicoscapular,  are 
then  approximated  and  secured  by  silkworm-gut  or  button  sutures. 
The  operation  is  one  of  the  severest  known  to  surgery,  and  requires 
often  the  maximum  of  speed.  It  should  never  be  undertaken  unless 
the  surgeon  is  equipped  with  the  best  assistance  and  every  facility  for 
controlling  severe  shock. 


Fig.  482. — The  needles  and  constrictor  applied:    circular  and  longitudinal  incisions  for 

skin  flap.     (Wyeth.) 


Amputation  at  the  Hip-joint. — What  has  just  been  said  in  regard  to 
the  removal  of  the  entire  upper  extremity  applies  with  equal  force  to 
amputation  at  the  hip-joint.  Formerly  the  operation  was  attended  by 
a  very  high  rate  of  mortality.  Of  late,  however,  owing  to  better 
means  of  controlling  hemorrhage  and  better  methods  of  effecting 
removal  of  the  limb,  the  death  rate  has  been  materially  lessened. 

Many  methods  of  controlling  hemorrhage  have  been  employed  in 
this  operation;  two  only  are  to  be  recommended,  that  by  the  rubber 
tourniquet  and  Wyeth's  pins,  and  that  by  compression  of  the  common 
iliac  through  an  abdominal  wound,  as  suggested  by  McBurney. 

In  the  Wyeth  method  (Fig.  4S2)  two  long  steel  pins  or  skewers  are 
thrust  through  the  soft  tissues,  the  first  pin  entering  just  below  and  a 
little  to  the  inner  side  of  the  anterior  superior  spinous  process  and 
emerging  on  a  level  with  the  point  of  entrance,  but  four  or  five  inches 
to  the  outer  side  of  the  limb.     Thesecond  pin  is  introduced  through 


958  AMPUTATIONS 

the  adductor  muscles,  near  the  ramus  of  the  pubes  and  to  the  inner  side 
of  the  femoral  vessels,  and  is  made  to  emerge  one  inch  in  front  of  the 
tuberosity  of  the  ischium.  After  protecting  the  points  of  these  pins 
by  corks,  a  firm  piece  of  rubber  tubing  is  wound  several  times  around 
the  limb  above  the  pins  and  secured  by  a  clamp.  If  an  Esmarch 
bandage  is  employed  previous  to  the  application  of  the  tourniquet, 
the  operation  will  be  practically  bloodless,  as  this  method  controls 
every  vessel  supplying  blood  to  the  field  of  operation. 

The  McBurney  plan  consists  in  preliminary  laparotomy  by  the 
intermuscular  method,  and  compression  of  the  common  iliac  artery 
by  the  hand  of  an  assistant  introduced  into  the  peritoneal  cavity.  The 
author  has  employed  this  plan,  but  without  opening  the  peritoneal 
cavity,  by  stripping  the  peritoneum  from  the  iliac  muscle  after  separa- 
tion of  the  muscular  fibres.  The  artery  is  as  easily  and  quickly 
exposed,  and,  after  the  operation  is  completed,  the  tissues  fall  readily 
into  place,  and  require  only  a  few  sutures  and  closure  of  the  cutaneous 
wound. 

While  both  of  these  methods  may  be  relied  upon  to  control  hemor- 
rhage absolutely,  the  author  would  prefer  the  Wyeth  method  in  a  case 
of  shock  where  speed  was  an  important  factor,  and  the  McBurney 
method  in  the  case  of  a  very  fleshy  individual. 

As  the  racket-shaped  amputation  has  practically  superseded  all  of 
the  older  methods,  it  alone  will  be  described.  For  a  description  of  the 
other  methods,  the  reader  is  referred  to  works  on  operative  surgery. 

The  operation  is  performed  in  the  following  manner:  The  patient 
is  placed  on  the  operating-table  with  the  hips  projecting  slightly  over 
the  edge.  The  sound  leg  is  held  out  of  the  way  by  one  assistant,  and 
the  diseased  limb  supported  in  the  extended  position  by  another. 
A  circular  incision  is  then  made  six  inches  below  the  tip  of  the  greater 
trochanter,  and  a  cuff  of  skin  and  subcutaneous  tissue  retracted.  A 
vertical  incision  is  then  made  down  to  the  bone  from  the  outer  side  of 
the  cutaneous  incision,  to  a  point  one  inch  above  the  greater  trochanter. 
The  two  triangular  flaps  thus  created  are  sharply  retracted  and  the 
bone  shelled  out  of  its  muscular  bed  by  sharp  and  blunt  dissection. 
The  capsule  of  the  joint  is  next  opened  and  disarticulation  effected  by 
strong  adduction  and  a  rotary  motion  of  the  limb.  As  soon  as  the 
bone  leaves  the  socket  the  posterior  muscular  attachments  are  severed 
and  the  limb  removed.  The  femoral  artery  and  vein  should  be  ligated 
separately.  Ligation  will  also  be  required  for  the  profunda  and 
descending  branch  of  the  external  circumflex. 

Some  operators  prefer  to  place  the  patient  on  the  sound  side,  and 
begin  by  making  the  vertical  incision,  entering  the  knife  one  inch 
above  the  trochanter,  carrying  the  incision  downward  parallel  with 
the  bone  for  five  inches,  then  encircling  the  limb.  After  dissecting  up 
to  the  skin  from  the  muscles  for  a  distance  of  two  or  three  inches,  the 
muscles  are  divided  to  the  bone  by  a  circular  sweep  of  the  knife  and 
the  head  disarticulated  as  in  the  other  method.     Rose  and  Carless 


SPECIAL   AMPUTATIONS  959 

advise  making  the  perpendicular  arm  of  the  incision  immediately  over 
the  femoral  vessels. 

It  is  important  after  this  operation  to  support  the  parts  by  a  firmly 
applied  dressing,  as  the  cut  muscular  surfaces  are  apt  to  ooze  consider- 
ably, and  if  the  dressings  are  loosely  applied  they  soon  become  saturated 
and  have  to  be  removed.  If  the  wound  is  aseptic,  it  is  desirable  to 
allow  the  primary  dressing  to  remain  in  place  for  ten  days  or  two  weeks. 

Amputation  of  the  Thigh. — Amputation  of  the  thigh,  like  amputa- 
tion of  the  arm,  may  be  performed  by  almost  any  one  of  the  methods 
described  in  the  beginning  of  the  chapter.  The  quickest  operation  is 
the  double-flap  method  by  transfixion,  and  is  indicated  in  old  and 
debilitated  subjects,  and  in  patients  suffering  from  severe  shock  or 
sepsis. 

The  osteoplastic  operation  gives  the  best  results,  if  viewed  from  the 
standpoint  of  subsequent  weight-bearing  function,  although  the  Teale 
method  also  gives,  as  a  rule,  an  insensitive  stump.  Conical  stump  is 
quite  common  in  amputations  of  the 
thigh,  especially  in  the  lower  third. 
This  is  due  largely  to  the  fact  that  the 
flexor  muscles  retract  much  more  than 
the  extensors,  leaving  the  bone  more  or 
less  exposed  and  covered  only  by  the 
skin.  To  remedy  this,  Dawbarn  begins 
the  operation  by  "  ham-stringing,"  his 
patient,  or  dividing  the  tendinous  at- 
tachments of  the  externa]  and  internal 
flexors  just  above  the  knee  by  a  stroke  of 
the  knife.  This  allows  retraction  to  take  fig.  483.— Amputation  by  lateral 
place  before  the  flaps  are  cut.     On  ac-  flaps.    (Roberts.) 

count  of  this  tendency  to  muscular  re- 
traction it  is  desirable  in  thigh  amputation  to  allow  a  redundency  of 
the  extensor  muscles  and  to  suture  them  to  the  ham-strings  over  the 
divided  extremity  of  the  bone.     For  this  purpose  buried  sutures  of 
chromicized  catgut  should  be  employed. 

Amputation  at  or  near  the  Knee-joint. — A  number  of  excellent  opera- 
tions have  been  devised  for  amputation  at  or  near  the  knee-joint. 

The  bilateral  flap  of  operation  of  Stephen  Smith  is  one  of  the  most 
popular,  and  has  the  advantage  that  the  scar  is  situated  posteriorly 
and  well  out  of  the  way  of  the  bearing  point.  A  curved  incision  is 
made,  beginning  one  inch  below  the  tubercle  of  the  tibia  and  extending 
downward  and  outward  over  the  fleshy  part  of  the  leg  to  a  point  behind 
on  the  calf  opposite  the  tubercle;  then  upward  in  a  vertical  direction 
to  the  middle  of  the  popliteal  space.  A  similar  incision  is  made  on 
the  inner  side  of  the  leg,  but  extending  about  one  inch  lower  on  the 
calf,  and  joining  the  first  in  front  and  behind.  These  incisions  are 
next  carried  down  to  the  bone,  forming  two  musculocutaneous  lateral 
flaps,  which  are  well  retracted  and  the  line  of  articulation  exposed. 


900 


AMPUTATIONS 


The  patellar  tendon  is  then  divided,  the  joint  opened,  the  leg  flexed, 
the  lateral  and  crucial  ligaments  divided,  the  knife  carried  behind  the 
head  of  the  tibia,  and  the  leg  severed  by  a  downward  stroke. 

Carden's  method  consists  in  a  supracondyloid  amputation  with  a 
long  anterior  and  a  short  posterior  flap.  A  curved  anterior  incision  is 
made  from  one  condyle  to  the  other,  extending  downward  to  the 
tubercle  of  the  tibia.     This  is  dissected  upward  to  a  point  above  the 


Fig.  484. — A,  Gritti's  amputation  at  the  knee;  A',  lines  of  division  of  the  bones;  B, 
amputation  of  the  thigh,  long  anterior  flap;  B',  division  of  the  bone;  C,  amputation 
at  the  lower  third  of  the  thigh;  C",  division  of  the  bone;  D,  disarticulation  at  the  hip- 
joint.     (Stimson.) 


patella.  A  posterior  incision  is  then  made  connecting  the  two  extrem- 
ities of  the  anterior  cut,  and  is  carried  through  all  the  soft  parts  to  the 
bone.  The  muscular  structures  on  the  anterior  aspect  of  the  thigh 
are  then  freely  incised  and  the  bone  sawed  just  above  the  condyles. 

The  Gritti  or  Stokes  Method  (Fig.  484). — This  is  an  osteoplastic  amputa- 
tion. A  curved  anterior  incision  is  made,  as  in  the  Garden  operation, 
extending  from  one  condyle  to  the  other  through  the  patellar  ligament. 


SPECIAL  AMPUTATIONS  961 

The  flap  is  retracted  strongly  upward,  the  leg  acutely  flexed,  and  the 
joint  freely  opened.  The  blade  of  the  knife  is  then  passed  behind  the 
head  of  the  tibia  and  a  short  posterior  flap  cut  from  within  outward. 
The  articular  surfaces  of  the  femur  and  patella  are  then  sawed  off, 
exposing  bone  tissue.  In  the  Gritti  operation  the  femur  is  sawed 
through  the  condyles;  in  the  Stokes  operation,  just  behind.  The 
latter  is  to  be  preferred,  as  its  cut  surface  more  accurately  fits  the 
patella. 

The  anterior  flap  with  the  adherent  patella  is  then  allowed  to  fall 
over  the  cut  surface  of  the  femur  and  is  sutured  to  the  edge  of  the 
posterior  incision.  If  any  tendency  to  displacement  of  the  opposed 
bony  surfaces  is  present,  they  are  held  by  one  or  more  chromicized 
catgut  sutures  passed  through  holes  drilled  in  the  two  bones.  It  is 
desirable  in  this  operation  to  remove  as  much  of  the  synovial  membrane 
as  possible,  and  to  touch  the  remaining  portions  with  pure  carbolic 
acid,  to  promote  adhesion  and  to  prevent  accumulation  of  synovia. 

Amputation  of  the  Leg. — In  the  upper  half  of  the  leg  the  circular  or 
the  transfixion  method  may  be  employed.  In  the  lower  portion  Teale's 
method  (Fig.  476)  or  the  long  posterior  flap  operation  is  to  be  preferred, 
depending  on  the  condition  of  the  soft  parts.  Bryant  advises  in  the 
lower  third  a  circular  amputation  with  a  periosteal  flap  cut  from  the 
subcutaneous  surface  of  the  tibia  and  retaining  its  connection  with  the 
skin.  After  division  of  the  bones  the  periosteal  flap  is  placed  over 
the  cut  surface  of  the  tibia  and  the  cutaneous  edges  united  obliquely, 
so  that  the  scar  lies  between  the  bones. 

In  all  amputations  of  the  leg  the  fibula  should  be  sawed  about  one- 
half  inch  above  the  tibia.  Bull  advises  an  oblique  section  of  the  crest 
of  the  tibia  before  closure  of  the  wound. 

Amputation  at  or  near  the  Ankle-joint. — The  Syme  Amputation. — 
Enter  the  knife  at  the  tip  of  the  external  malleolus  and  carry  the 
incision,  extending  to  the  bone,  directly  downward  and  then  across  the 
sole  to  a  point  half  an  inch  below  the  tip  of  the  internal  malleolus. 
Dissect  this  heel  flap  backward  from  the  os  calcis  until  the  tendo 
Achillis  is  reached.  Then  connect  the  two  extremities  of  the  plantar 
incision  by  an  oval  anterior  incision  approximated  at  right  angles  to 
the  plantar,  dividing  all  the  soft  parts  to  the  bone.  The  joint  is  next 
opened  from  in  front,  the  lateral  ligaments  divided,  and  the  foot 
removed.  The  flaps  should  then  be  retracted  upward,  and  the  malleoli, 
or  even  the  entire  articular  surface  of  the  bones,  removed.  After 
traction  on  and  division  of  the  exposed  tendons,  and  ligature  of  the 
vessels,  the  flaps  are  approximated  and  united.  Drainage  may  be 
secured  from  the  angles  of  the  wound  or  by  means  of  a  separate  opening 
at  the  bottom  of  the  cup-shaped  dead  space  in  the  heel  flap. 

The  Pirogoff  Operation  (Fig.  485). — The  incisions  for  this  operation 

are  practically  the  same  as  in  Syme's,  the  plantar  cut  being  made 

about  half  an  inch  further  forward.     The  heel  flap  is  dissected  from 

the  os  calcis  only  about  one  inch  from  the  incision,     The  joint  is  then 

61 


902 


AMPUTATIONS 


opened,  the  lower  ends  of  the  tibia  and  fibula  removed,  and  the  cal- 
caneum  sawed  obliquely  through  in  the  line  of  the  plantar  incision, 
removing  its  articular  surface  and  leaving  the  posterior  portion  attached 
to  the  heel  flap.     When  the  heel  flap  is  raised  up,  the  cut  surface  of  the 


Fig.  485. 


-Pirogoff's  amputation:    A,  cutaneous  incision  (outer  side);    B,  line  of  section 
of  the  bones.     (Stimson.) 


calcaneum  is  brought  in  contact  with  the  cut  surface  of  the  tibia  and 
held  in  that  position  by  the  cutaneous  sutures.  This  gives  an  excellent 
stump  with  but  little  shortening  of  the  limb. 

The  Roux  Operation  (Fig.  486). — Enter  the  knife  one-half  inch  above 
the  insertion  of  the  tendo  Achillis,  carry  the  incision  by  a  downward 
curve  beneath  the  external  malleolus  over  the  dorsum  of  the  tarsus  to 


Fig.  486. — Amputation  through  the  ankle-joint  by  large  internal  lateral  flap.     (Roux.) 


a  point  in  the  middle  of  the  instep  one  inch  in  front  of  the  articular 
edge  of  the  tibia,  then  downward  and  inward  to  the  middle  of  the 
sole,  and  backward  and  upward  to  the  point  of  the  beginning.  Carry 
the  incision  to  the  bone  throughout  and  raise  the  plantar  flap.     Open 


SPECIAL  AMPUTATIONS  963 

the  joint  from  the  outside,  remove  the  foot,  saw  off  the  malleoli,  and 
unite  the  flap  with  silkworm  gut. 
Midtarsal  amputations  are  not  to  be  recommended. 
The  Lisfranc  Amputation. — Disarticulation  of  the  tarsometatarsal  joint. 
— Extend  the  foot  and  make  an  anterior  curved  incision  from  a 
point  just  in  front  of  the  base  of  the  first  to  the  base  of  the  fifth 
metatarsal  bone.  Divide  all  the  tissues  down  to  the  bone  and  separate 
the  metatarsal  bones  from  the  cuboid  and  the  cuneiform  bones,  remem- 
bering that  the  middle  cuneiform  bone  is  shorter  than  its  fellows,  and 
that  the  second  metatarsal  bone  projects  upward  into  this  mortice. 
When  the  joint  is  freely  opened,  pass  the  blade  of  the  knife  behind 
the  metatarsal  bones  and  cut  a  thick  U-shaped  flap  from  the  plantar 
surface  of  the  foot  to  the  base  of  the  toes.  Next  remove  all  fragments 
of  tendons,  ligate  the  bleeding  vessels,  and  turn  the  plantar  flap  upward 
and  attach  it  to  the  dorsal  by  a  sufficient  number  of  silkworm-gut 
sutures. 

Heys  operation  differs  from  this  in  that  he  removes  the  lower 
projecting  extremity  of  the  inner  cuneiform  bone. 

In  Skey's  operation  the  base  of  the  second  metatarsal  bone  is  sawed 
off  even  with  the  internal  cuneiform. 

Amputation  at  the  Metatarsophalangeal  Joints. — Amputation  at  the 
metatarsophalangeal  joints,  or  disarticulation  of  all  the  toes,  is  an 
operation  rarely  called  for  except  for  gangrene  from  frost-bite  or  Ray- 
naud's disease.  Both  dorsal  and  plantar  flaps  should  be  cut  to  the 
web  of  the  toes,  and  an  attempt  made  to  bring  the  scar  as  near  the 
dorsal  aspect  of  the  stump  as  possible. 

Amputation  of  the  Toes. — Amputation  of  the  toes  are  carried  out 
by  the  same  methods  as  in  amputation  of  the  fingers.  In  the  metatar- 
sophalangeal disarticulation  the  bilateral  flap  or  racket  method  is 
usually  employed.  In  disarticulation  of  the  terminal  phalanges  the 
long  plantar-flap  method  is  to  be  preferred. 


CHAPTER  XXXIII. 
DEFORMITIES  AND  THEIR  CORRECTION. 

Scoliosis,  or  Rotary  Lateral  Curvature  of  the  Spine. — Scoliosis  is 
usually  an  acquired,  though  occasionally  a  congenital  deformity  of  the 
spine,  characterized  by  a  more  or  less  well-marked  lateral  bending 
and  twisting  of  the  spinal  column,  and  consequent  asymmetry  in  the 
appearance  of  the  thorax,  abdomen,  and  extremities.  The  disease 
develops  in  the  majority  of  instances  before  the  tenth  year,  and  is 
far  more  common  in  girls  than  in  boys. 

A  slight  compensatory  curve  in  the  spine  will  result  from  a  faulty 
position  of  the  head,  shoulder,  or  body,  habitually  assumed  in  standing, 
walking,  or  sitting;  also  from  an  inequality  in  the  length  of  the  legs, 
or  from  an  asymmetric  development  of  the  pelvis  or  muscles.  Broadly, 
however,  etiological  factors  may  be  classified  as  primary  and  secondary. 
Under  primary  causes  come  congenital  deformity,  rickets,  and  occupa- 
tions leading  to  an  habitual  faulty  position.  Secondary  causes  are 
the  previous  existence  of  paralysis  or  deformities  of  the  extremities, 
diseases  of  the  various  systems  of  the  thoracic  organs,  or  defects  in 
sight  or  hearing.  These  secondary  causes  give  rise  to  compensatory 
curvatures  of  the  spine,  which  naturally  increase  with  age  and  growth, 
and  correspondingly  are  corrected  with  increasing  difficulty.  At 
length  changes  occur  in  the  vertebra3,  as  atrophy  of  the  vertebral 
bodies  on  the  concave  side  and  thickening  on  the  convex  aspect, 
distortion  of  the  sagittal  plane,  and  general  asymmetry  of  the  individual 
vertebrae,  resulting  in  permanent  deformity. 

As  the  spine  is  bent,  rotation  on  its  vertical  axis  occurs.  In  this 
rotation  the  bodies  of  the  vertebrae  are  directed  toward  the  convexity 
of  the  lateral  curve,  which  causes  a  bulging  of  the  costal  arches  poste- 
riorly on  that  side,  with  a  compensatory  retraction  of  the  thorax  on 
the  opposite  side.  This  distortion  of  the  thorax  causes'pressure  on  its 
contained  viscera,  occasionally  resulting  in  pathologic  changes. 
Atrophy  and  lengthening  of  the  ligaments  and  muscles  are  observed 
on  the  convex  side  of  the  curve,  with  shortening  of  these  structures 
on  the  concave  side. 

Symptoms. — The  symptoms  of  scoliosis  are,  in  the  earlier  stages, 
simply  the  occurrence  of  "round  shoulders"  in  a  child,  a  lowering  of 
one  shoulder,  or  a  slight  departure  from  the  normal  erect  position 
of  the  body  in  standing  or  walking.  Occasionally,  however,  symptoms 
of  weakness  and  awkwardness  may  precede  the  deformity,  or  at  least 
may  cause  its  observation,  together  with  general  indifference,  laziness, 
and  lack  of  co-ordination  and  muscular  control.  There  is  also  a'change 
of  asymmetry  in  the  triangles  formed  by  the  dependent  armsjmd  the 


SPONDYLOLISTHESIS 


905 


lateral  aspects  of  the  trunk.  This  easily  may  be  corrected  by  voluntary 
effort  on  the  part  of  the  patient,  but  the  corrected  posture  is  tiresome 
and  the  child  soon  assumes  the  faulty  one.  As  the  disease  progresses 
the  postural  deformity  becomes  more  marked,  and  an  abnormal 
prominence  of  the  ribs  may  be  noticed  on  one  side,  especially  when  the 
child  bends  forward  and  the  thorax  is  examined  from  behind.  Exces- 
sive prominence  of  one  hip,  the  fact  that  the  nipples  are  not  in  the  same 
horizontal  plane,  or  that  one  scapula  is  more  prominent  than  the  other, 
should  also  be  regarded  as  signs  of  scoliosis.  On  examining  the  patient 
from  behind  and  applying  friction  to  the  spine,  the  extent  of  curve 
can  be  appreciated  by  observing  the  red  line  of  the  spinous  processes. 
Fig.  487  shows  an  example  of  a  well- 
marked  type  of  the  disease. 

Treatment. — In  the  early  stages  of  the 
disease  the  treatment  should  consist  in 
removing  the  cause  of  the  faulty  atti- 
tude, and  in  the  use  of  light  gymnas- 
tic exercises  to  develop  the  weakened 
muscles  which  are  employed  to  hold  the 
body  in  a  correct  posture.  For  this  pur- 
pose the  ordinary  setting-up  drill  of 
military  tactics  is  the  one  to  be  recom- 
mended. If  the  disease  is  more  ad- 
vanced, heavy  gymnastics  to  over- 
develop the  muscles,  are  often  of 
advantage.  Supporting  corsets  of  plas- 
ter of  Paris,  paper,  or  leather,  are  often 
employed  to  hold  the  body  in  a  normal 
position  if  the  muscles  are  easily  tired 
and  the  child  constantly  assumes  faulty 
attitudes  which  tend  to  exaggerate  the 
deformity. 

In  the  severer  cases  in  which  there 
is  fixed  bony  deformity,  forcible  cor- 
rection by  means  of  traction  straps,  and  the  application  of  a  plaster 
jacket,  while  the  patient  is  held  in  the  corrected  position,  constitute 
the  best  treatment.  A  few  days  or  weeks  later  another  jacket  is 
applied  in  the  same  manner,  and  when  the  deformity  is  finally  overcome 
a  removable  leather  or  celluloid  jacket  should  be  worn,  and  heavy 
gymnastics  practised  daily.  Metal  braces  are  occasionally  useful 
for  this  condition.  More  favorable  results  have  lately  been  achieved 
by  the  Abbott  jacket,  or  by  the  modification  of  Dr.  Abbott's  principle, 
the  Kleinberg  brace.  For  a  description  of  these  the  reader  is  referred 
to  a  work  on  orthopedic  surgery. 

The  prognosis  in  advanced  cases  is  not  favorable. 

Spondylolisthesis. — Spondylolisthesis  is  an  extremely  rare  deformity, 
due  to  a  subluxation  forward  of  one  of  the  lower  lumbar  vertebrae  or  a 


Fig.    487. — Severe    lateral    curva- 
ture (back  view).     (Lovett.) 


966 


DEFORMITIES  AND  THEIR  CORRECTION 


projection  forward  of  the  upper  sacral  segment.  This  may  occur 
as  a  result  of  some  congenital  defect  or  an  abnormal  position  of  the 
spine  during  intra-uterine  life  of  the  fetus;  or  it  may  develop  during 
childhood  or  adult  life  from  trauma,  overstrain,  or  disease  of  the  lumbo- 
sacral joint.  As  a  result  of  this  displacement  there  is  an  abnormal 
increase  in  the  lumbar  curve  of  the  spine  (excessive  lordosis),  a  diminu- 
tion in  the  normal  obliquity  of  the  pelvis,  causing  tension  on  the 
anterior  ligaments  of  the  hip  and  a  consequent  flexed  position  of  the 
thighs  (Bradford  and  Lovett).  The  typical  deformity  is  usually 
seen  in  women,  and  first  therein  diagnosed  because  of  its  influences  on 
parturition. 

Symptoms. — The  symptoms  of  the  disease  are  a  faulty  position  when 
standing  and  a  peculiar  waddling,  duck-like  gait,  sometimes  almost 

ataxic  in  character.  Pain  in  the 
lumbar  region  radiating  down  the 
limbs  is  common. 

When  standing  erect,  the  body 
is  bent  forward,  there  is  a  marked 
prominence  of  both  hips,  and  the 
thorax  seems  abnormally  near  the 
pubic  crest.  Complete  extension 
of  the  thighs  is  impossible  (Fig. 
488).  Vaginal  or  rectal  examina- 
tion reveals  the  presence  of  a  prom- 
inent sacral  or  sacrolumbar  bony 
projection. 

The  disease  resembles  closely 
double  congenital  dislocation  of 
the  hip,  but  can  be  distinguished 
from  that  malady  by  the  absence 
of  vertical  mobility  of  the  femur, 
and  the  fact  that  the  trochanters 
are  not  above  Nekton's  line. 
Treatment  in  the  cases  in  which 
there  is  pain,  or  in  which  the  de- 
formity is  the  result  of  injury 
should  be  by  means  of  a  spinal  brace  or  strong  corset.  In  young  sub- 
jects exercises  to  prevent  limitation  of  flexion,  and  the  avoidance  of 
postures  favoring  deformity  are  indicated. 

Congenital  Dislocation  of  the  Hip. — Congenital  dislocation  of  the  hip 
is  a  comparatively  rare  malformation,  but  the  most  common  and  most 
important  of  the  congenital  displacements.  Over  80  per  cent,  of  cases 
occur  in  girls.  In  almost  one-third  of  the  cases  the  disease  is  double. 
In  this  condition  the  head  of  the  femur  occupies  a  position  above 
and  behind  or  in  front  of  the  acetabulum.  The  capsule  of  the  joint 
is  still  adherent  to  the  rim  of  the  acetabulum,  but  is  markedly  thick- 
ened and  elongated,  so  that  the  lower  portion  adherent  to  the  acetabular 


Fig.  488. — Spondylolisthesis. 


\ '■/■'/■:. \T VENT  OF    CONGENITAL    DISLOCATION  OF  THE  III/'     967 


rim  is  contracted  and  the  upper  and  inner  portion  is  firmly  attached 
to  the  new  socket.  The  head  of  the  bone  in  these  cases  is  often  under- 
developed, and  the  acetabulum  shallow  and  filled  with  fibrous  tissue 
and  fat. 

Diagnosis. — The  diagnosis  of  congenital  dislocation  is  often  difficult 
in  young  and  fat  children.  As  a  rule,  these  children  walk  late,  and  the 
gait  is  a  peculiar  waddling  one,  accompanied  by  an  exaggerated 
swaying  of  the  body.  The  hips 
are  exceedingly  prominent  and 
the  perineal  space  widened.  The 
trochanters  are  above  Nekton's 
line,  and  the  head  of  the  bone 
occasionally  may  be  felt  on  the 
dorsum  of  the  ilium,  though  of 
more  importance  is  the  fact  that 
it  cannot  be  felt  in  its  normal 
position.  There  is  marked  com- 
pensatory lordosis,  and  the  femur 
can  be  moved  upward  and  down- 
ward for  an  inch  or  more  (Fig. 
489).  There  is  no  history  of  in- 
jury. 

Treatment. — Two  methods  of 
treatment  are  in  use  for  the  cor- 
rection of  this  deformity:  reduc- 
tion by  manipulation  or  the  blood- 
less operation  of  Lorenz,  and  the 
method  by  open  operation  recom- 
mended by  Hoffa.  The  former  is 
to  be  recommended  in  children 
between  the  ages  of  two  and  eight, 
although  it  is  occasionally  success- 
ful between  ten  and  thirteen  years 
of  age;  the  latter  operation  after 
the  age  of  ten  and  in  cases  in 
which  the  method  by  manipula- 
tion has  failed  or  where  relapses 
have  occurred. 

Lorenz  s  method  consists  in  overstretching  and  rupturing  the  con- 
tracted and  shortened  muscles  by  traction,  extreme  abduction,  flexion, 
and  extension,  and  subsequently  effecting  reduction  by  manipulation, 
as  in  acquired  dislocations.  The  limb  is  then  placed  in  a  position  of 
extreme  abduction  and  held  by  a  firm  plaster  spica,  which  should  be 
left  in  place  for  from  six  to  eight  months.  After  its  removal  the  leg 
gradually  should  be  brought  into  normal  position. 

Hoffa  s  method  consists  in  making  an  incision  from  the  anterior 
superior  spinous  process  downward  and  backward,  passing  behind 


Fig.  489. — Lordosis  and  prominence  of 
trochanter  in  congenital  dislocation  of  hip. 
(J.  S.  Stone.) 


•MIS 


DEFORMITIES  AND   THEIR  CORRECTION 


the  greater  trochanter.  This  incision  is  deepened  until  the  capsule 
of  the  joint  is  exposed.  The  soft  parts  are  then  thoroughly  retracted, 
the  capsule  opened,  the  acetabulum  examined  and  its  contents  removed, 
the  head  of  the  bone  dislocated  from  its  false  position  and  placed  in  the 
socket.  The  capsule  is  then  sutured,  the  wound  closed  with  drainage, 
and  the  thigh  fixed  in  a  position  of  flexion  and  abduction  by  a  plaster 
cast. 

Osteotomy  may  be  necessary  later  to  bring  the  limb  into  proper 
position. 

Congenital  dislocations  of  the  knee,  patella,  ankle,  shoulder,  elbow, 
and  wrist  are  extremely  rare.  For  a  description  of  them  the  reader  is 
referred  to  works  ou  orthopedic  surgery. 


Fig.  490. — Cross-section  of  the  pelvis  and  the  deformed  femur.  A  scheme  to  show 
the  effect  of  the  deformity  in  limiting  abduction  of  the  limb.  The  dotted  outline  shows 
the  normal  relation.     (Whitman.) 


Coxa  Vara. — Under  normal  conditions  in  childhood  the  angle  of 
junction  of  the  axis  of  the  neck  of  the  femur  with  that  of  the  shaft  is 
an  obtuse  one.  As  a  result  of  complete  or  incomplete  fracture  of  the 
neck  of  the  femur  in  childhood,  or  as  a  result  of  other  abnormal  con- 
ditions, the  exact  nature  of  which  is  not  well  understood,  a  bending 
of  the  neck  occurs  so  that  its  junction  with  the  shaft  approaches  a 
right,  or  even  an  acute,  angle.  This  results  in  an  elevation  of  the 
trochanter  which  may  be  well  above  Nelaton's  line,  an  adduction  and 
evcrsion  of  the  limb,  and  an  inability  to  abduct  the  thigh  beyond  a 
certain  point  (Fig.  490). 


DIAGNOSIS  OF  KNOCK-KNEE  000 

In  double  coxa  vara  the  abduction  may  be  so  marked  that  the  legs 
are  habitually  crossed,  and  locomotion  becomes  greatly  embarrassed 
or  even  impossible. 

Symptoms. — The  symptoms  of  this  condition  are  at  first  irritation 
about  the  hip-joint,  with  unusual  fatigue  on  walking,  slight  limping, 
a  peculiar  swaying  gait,  and,  in  double  coxa  vara,  a  well-marked 
lordosis  on  standing.  The  limb  is  shortened,  the  foot  everted,  and 
the  trochanter  is  felt  higher  than  normal.  Extreme  abduction  is  lim- 
ited by  contact  of  the  tip  of  the  trochanter  against  the  rim  of  the 
acetabulum.  The  condition  is  occasionally  associated  with  rickets, 
and  scoliosis  frequently  results  when  the  disease  is  unilateral. 

Treatment. — The  treatment,  as  advised  by  Whitman,  should  consist 
in  subtrochanteric  osteotomy,  correction  of  the  deformity  by  extreme 
abduction,  and  fixation  of  the  limb  in  this  position  by  a  plaster  cast 
until  the  bone  is  firmly  united. 

In  cases  of  traumatic  coxa  vara,  where  the  patient  is  seen  before 
solid  union  has  taken  place,  or  in  cases  due  to  rickets,  where  the 
bone  is  still  soft  and  yielding,  the  deformity  sometimes  can  be  reduced 
by  manipulation  (extreme  abduction),  after  which  it  should  be  held 
in  the  corrected  position  by  plaster,  as  after  operation. 

Coxa  Valga. — A  rare  condition,  the  reverse  of  coxa  vara,  in  which 
the  angle  made  by  the  shaft  and  neck  is  more  obtuse  than  normal. 
The  diagnosis  is  rarely  made  except  by  the  z-rays.  A  few  cases  have 
been  reported  as  being  relieved  by  an  osteotomy  of  the  neck  and 
correction  of  the  deformity  by  elevating  the  limb. 

Knock-knee. — Knock-knee  is  an  internal  angular  curvature  of  the 
lower  extremity,  the  apex  of  the  angle  being  at  the  knee-joint.  This 
occurs  chiefly  in  infancy  and  early  youth.  In  the  infantile  variety 
it  is  generally  due  to  rickets,  and  the  deformity  may  occur  before 
attempts  at  walking  have  been  made.  Generally,  however,  the 
deformity  appears  with  the  first  attempts  at  walking,  and  shows 
a  strong  tendency  to  progress  as  the  use  of  the  limbs  is  increased. 
In  the  adolescent  type  the  disease  appears  between  the  ages  of  ten 
and  eighteen,  and  is  commonly  associated  with  occupations  requiring 
constant  standing. 

The  chief  pathologic  factors  of  the  deformity  are  increased  length 
of  the  internal  condyle  of  the  femur  and  atrophy  of  the  external, 
with  or  without  changes  in  the  head  of  the  tibia.  With  this  there 
may  be  a  curve  in  the  shaft  of  the  femur  and  relaxation  of  the  internal 
lateral  ligament  of  the  joint. 

Diagnosis. — The  diagnosis  is  easily  made  by  inspection  (Fig.  491).  In 
double  knock-knee  the  gait  is  peculiar,  owing  to  the  necessity  of  separat- 
ing the  thighs  to  allow  the  advancing  knee  to  pass  its  fellow  in  walking. 

If  the  legs  are  flexed  on  the  thighs,  the  deformity  partly  disappears; 
if  the  thighs  are  also  flexed,  the  deformity  may  be  completely  absent. 
In  the  extended  position  the  examination  should  always  be  made  with 
the  condyles  flat  on  the  examining  table. 


970 


DEFORMITIES  AND   THEIR  CORRECTION 


With  well-marked  knock-knee  there  are  often  an  external  rotation 
of  the  tibia  and  flat-foot. 

Treatment. — In  the  earliest  stage,  up  to  four  years  of  age,  the  deform- 
ity may  be  corrected  by  massage,  general  tonic  measures,  and  proper 


-^ 


Fig.  491. — Knock-knee.     (Whitman.) 

braces  applied  to  the  legs.  In  the  severer  forms,  and  after  four  years 
of  age,  operative  treatment  only  is  to  be  recommended;  and  of  the 
various  methods,  supracondyloid  osteotomy  gives  the  best  results. 
It  is  performed  as  follows: 


Fig.  492. — Osteotome. 


The  knee  should  be  flexed  and  the  limb  placed  on  a  sand-bag  with 
the  inner  surface  uppermost.  A  small  vertical  incision  is  made 
one  inch  above  the  adductor  tubercle  and  an  osteotome  (Fig.  492) 
introduced,  turned,  and  its  cutting  edge  applied  transversely  to  the 


BOW-LEGS 


971 


long  axis  of  the  hone.  With  a  mallet  the  osteotome  is  driven  three- 
quarters  through  the  bone,  care  being  taken  to  cut  through  cortex 
both  above  and  below.  The  leg  is  next  extended,  the  limb  grasped 
above  and  below  the  joint,  and  the  femur  fractured.  The  deformity 
is  then  overcorrected  sufficiently  to  simulate  well-marked  bow-leg 
and  the  limb  placed  in  a  plaster  cast,  after  suture  of  the  wound,  and 
the  application  of  a  pad  of  sterile  gauze.  The  plaster  bandage  is 
worn  for  from  four  to  six  weeks,  and  should  then  be  supplemented  in 
young  subjects  by  a  brace,  which  should  be  worn  for  several  months, 
because  of  the  laxity  of  the  ligaments  of  the  knee-joint.  Massage 
and  exercise  should  also  be  employed. 


Fig.  493.— Bow-legs.     (Lovett.) 


Bow-legs. — This  deformity,  which  consists  in  an  outward  curvature 
of  the  limb,  is,  like  knock-knee,  commonest  in  children.  It  rarely 
occurs  before  early  attempts  at  walking  have  been  made  or  after  the 
fourth  year,  and  is  almost  always  due  to  rickets.  It  is  more  common 
than  knock-knee,  the  proportion  being  about  8  to  5. 

In  this  condition  the  deformity  is  caused  by  a  bending  of  the  femur 
or  tibia,  or  of  both  combined,  from  inability  of  the  softened  bones  to 
support  the  weight  of  the  body. 

In  the  majority  of  cases  there  is  a  gradual  outward  bowing  of  both 
the  femur  and  tibia.  In  other  cases  the  bending  is  limited  to  the 
lower  third  of  the  tibia.  In  some  instances  there  is,  in  addition  to 
the  outward  curve,  an  anteroposterior  curve  of  one  or  both  bones, 
the  convexity  being  forward.  Flat-foot  is  generally  present  (Fig. 
491)  in  rachitic  cases.     In  other  cases  flat-foot  as  an  accompanying 


972 


DEFORMITIES  AND  THEIR  CORRECTION 


deformity  is  rare,  as  the  relation  of  the  bones  is  such  that  the  body 
weight  falls  on  the  outer  rather  than  on  the  inner  side  of  the  foot. 

It  occasionally  happens  that  bow-leg  and  knock-knee  are  seen  in  the 
same  individual  (Fig.  494). 

Diagnosis. — The  diagnosis  is  easily  made.  The  child  stands  with 
the  feet  apart;  the  knees  are  widely  separated  and  the  feet  everted. 


Fig.  494. — Knock-knee  and  bow-leg.     (Whitman.) 


On  walking,  the  body  sways  from  side  to  side,  and  the  child  instinctively 
attempts  to  invert  the  feet  to  help  maintain  his  equilibrium.  To 
determine  whether  the  femur  is  involved,  the  legs  are  crossed  until 
the  knees  are  in  contact;  if  an  oval  separation  of  the  thighs  still  exists, 
there  is  curvature  of  the  femur.  Spontaneous  cure  of  the  deformity 
without  treatment  undoubtedly  occurs  in  certain  cases,  the  number 
of  such  cases  being  greater  than  in  knock-knee. 


CLUB-FOOT  973 

Treatment. — As  soon  as  a  tendency  to  bow-legs  is  noticed,  walking 
should  be  discouraged  and  a  vigorous  tonic  and  antirhaehitic  treatment 
inaugurated.  Steel  braces  and  other  forms  of  supporting  apparatus 
may  be  useful,  up  to  four  years  of  age,  to  prevent  increase  in  the 
deformity.  Gradual  correction  by  bending  the  limbs  and  maintaining 
the  position  by  plaster  casts  will  bring  about  a  cure  in  cases  in  which 
the  bones  are  still  soft.  After  the  bones  have  become  hardened,  how- 
ever, operative  treatment  is  indicated.  Osteotomy  of  the  tibia  or 
femur,  or  of  both  combined,  at  the  point  or  points  of  greatest  curvature, 
with  immediate  overcorrection  of  the  deformity  and  the  application 
of  a  plaster  cast  to  the  entire  limb,  including  the  pelvis,  is  the  method 
of  choice. 

Club-foot. — The  term  club-foot  is  generally  employed  to  indicate 
any^deformity,  either  congenital  or  acquired,  which  interferes  with  the 
normal  plantigrade  attitude  of  the  foot  in  walking.  Used  in  this  sense, 
the  term  is  synonymous  with  the  word  talipes,  which  literally  signifies 
a  walking  upon  the  ankle  or  tarsus,  a  condition  often  present  in  the 
severer  grades  of  club-foot.  Four  regular  varieties  of  club-foot  are 
described:  talipes  varus,  in  which  the  foot  is  turned  inward;  talipes 
valgus,  in  which  the  foot  is  turned  outward;  talipes  equinus,  in  which 
the  foot  is  in  a  position  of  extreme  plantar  flexion;  and  talipes  calcaneus, 
in  which  the  foot  is  in  a  position  of  extreme  dorsal  flexion.  Clinically, 
these  forms  are  often  associated,  as  in  talipes  equinovarus  and  talipes 
calcaneovalgus. 

The  causes  of  congenital  club-foot  are  not  well  understood,  but 
most  authorities  agree  that  the  deformity  is 'probably  due  to  some 
restriction  to  the  free  motions  of  the  foot  and  ankle  during  intra-uterine 
life  and  to  arrested  development.  The  causes  of  acquired  club-foot 
are,  in  the  order  of  their  frequency:  infantile  paralysis,  which  allows 
the  foot  to  be  drawn  out  of  place  by  the  action  of  certain  unopposed 
muscles;  the  various  forms  of  spastic  paralysis,  which  cause  contraction 
of  certain  muscles  or  groups  of  muscles;  the  effects  of  scars  from  burns, 
lacerations,  and  deep-seated  suppuration;  and  the  results  of  certain 
injuries  and  diseases  of  the  bone  and  joints. 

Talipes  Equinovarus,  or  Congenital  Club-foot. — This  is  by  far  the 
most  frequent  form  of  the  affection,  it  being  the  deformity  present 
in  77  per  cent,  of  the  congenital  cases.  It  is  often  associated  with 
spina  bifida  and  other  congenital  malformations.  The  deformity 
consists  in  an  inward  dislocation  of  the  anterior  part  of  the  foot  at 
the  mediotarsal  articulation.  With  this  there  is  also  contraction 
of  the  plantar  fascia,  the  Achilles  tendon,  and  the  tendons  of  the 
tibialis  anticus  and  posticus  muscles  (Fig.  495).  In  the  severest 
cases  the  bones  are  deformed  and  their  normal  relations  changed. 

In  the  acquired  form  of  talipes  equinovarus  the  disease  is  generally 
due  to  anterior  poliomyelitis,  and  the  deformity  closely  resembles 
the  congenital  form. 


974  DEFORMITIES  AND   THEIR  CORRECTION 

Talipes  valgus  is  usually  an  acquired  affection,  and  will  be  con- 
sidered in  the  section  devoted  to  Flat-foot. 

Talipes  equinus  is  occasionally  seen  as  a  congenital  affection,  but 
is  much  more  common  in  the  acquired  form.  In  these  cases  it  is 
due  to  paralysis  of  the  anterior  muscles  of  the  leg,  to  contraction 
of  the  soleus  and  gastrocnemius,  to  a  falling  downward  of  the  foot 
during  long  periods  of  recumbency,  and  as  a  compensatory  length- 
ening of  the  limb  after  fracture  and  other  conditions  associated  with 
shortening.  The  deformity  consists  in  an  extreme  position  of  plantar 
flexion.  The  heel  is  elevated  and  the  patient  walks  upon  the  distal 
extremities  of  the  metatarsal  bones  (Fig.  496),  or,  in  more  marked 


Fig.  495. — Congenital  talipes  equinovarus  (club-foot).     (Whitman.) 

cases,  the  toes  may  be  flexed  and  their  dorsal  surfaces  may  be  applied 
to  the  ground.  Occasionally  the  deformity  is  associated  with  valgus 
or  varus. 

Talipes  calcaneus  is  much  rarer  than  the  preceding.  It  is  more 
common,  however,  as  an  acquired  than  as  a  congenital  defect.  It  is 
frequently  associated  with  a  certain  amount  of  inversion  or  eversion 
of  the  foot. 

In  this  form  the  heel  is  depressed  and  the  anterior  portion  of  the 
foot  elevated.     The  patient  walks  upon  the  heel. 

Pes  cavus  is  a  term  applied  to  an  acute  arching  of  the  sole  of  the 
foot.  This  is  often  associated  with  the  different  varieties  of  talipes, 
and  is  the  opposite  of  pes  planus,  or  flat-foot. 


CLUB-FOOT 


975 


Treatment. — The  treatment  of  congenital  club-foot  should  be 
inaugurated  at  the  earliest  possible  moment.  During  the  first  few 
weeks  after  birth  the  nurse  or  mother  should  be  taught  to  correct 
the  deformity  several  times  each  day  by  gently  pressing  the  foot  into 
a  normal  position  with  the  hands.  At  a  later  period  the  surgeon 
should  attempt  to  overcorrect  the  deformity  by  manipulation,  and  to 
maintain  the  position  thus  obtained  by  the  application  of  adhesive 
straps  or  a  plaster-of-Paris  cast  in  which  a  flat,  wooden  sole  has  been 
imbedded.  Persistent  efforts  by  this  method  will  result  in  a  cure  in 
the  majority  of  cases. 

If,  however,  the  condition  has  been  neglected  until  the  soft  tissues 
are  less  yielding,  and  the  bones  are  firmer  and  deformed  by  walking, 
which  always  tends  to  increase  the 
deformity,  operative  methods  must 
be  employed.  These  should  be 
tried  in  the  following  order:  First, 
forcible  correction  of  the  deform- 
ity, under  general  anesthesia,  by 
manipulation  or  by  the  use  of  var- 
ious forms  of  apparatus,  and  the 
subsequent  application  of  a  plaster 
cast.  Second,  division  of  the  tendo 
Achillis,  with  subsequent  correction 
of  the  deformity  by  manipulation. 
Third,  division  of  the  tendons  of  the 
tibialis  anticus  or  posticus.  Fourth, 
incision  of  all  the  resisting  struct- 
ures on  the  inner  side  of  the  foot, 
down  to  the  bone,  the  incision  be- 
ginning just  in  front  of  and  a  little 
below  the  internal  malleolus,  and 
extending  to  the  outer  side  of  the 
neck  of  the  astragalus  (Phelps). 
Fifth,  the  removal  of  a  wedge- 
shaped  piece  of  bone  from  the  outer 

side  of  the  os  calcis  or  astragalus,  or  removal  of  the  entire  astragalus. 
In  the  early  non-operative  treatment  of  club-foot,  and  after  any 
of  the  above-mentioned  operative  procedures,  the  greatest  care  should 
be  exercised  to  prevent  a  relapse.  For  this  purpose  the  various 
kinds  of  club-foot  shoes  or  braces  will  be  found  of  value.  A  description 
of  these  may  be  found  in  any  work  on  orthopedic  surgery. 

For  the  treatment  of  talipes  equinus,  division  of  the  tendo  Achillis 
is  all  that  is  required  in  the  majority  of  cases. 

In  severe  cases  of  paralytic  origin,  whether  of  equinus  or  calcaneus, 
astragal ectomy  with  backward  displacement  of  the  foot  upon  the 
malleoli,  often  combined  with  tendon  transplantations,  has  given 
by  far  the  most  satisfactory  results.     The  early  employment  of  this 


Fig.  490. — Talipes  equinus.     (Lovett.) 


970  DEFORMITIES  AND   THEIR  CORRECTION 

operation  will  prevent  the  atrophy  and  distortion  of  the  foot  that  is 
usually  seen  in  late  neglected  cases. 

Flat-foot. — This  condition,  better  spoken  of  as  "weak-foot,"  is 
a  disability  whose  characteristic  in  all  stages  is  a  persistence  of  the 
passive  attitude  of  abduction,  in  place  of  normal  alternation  of  posture. 
This  disuse  of  the  functional  capacity  of  the  foot  is  followed  by  restric- 
tion of  motion,  particularly  in  the  range  of  adduction  and  plantar 
flexion,  which  restriction  gradually  develops  into  a  deformity.  This 
deformity  is  simply  an  exaggeration  of  the  normal  posture  assumed 
when  the  foot  supports  weight.  An  analysis  of  the  deformity  is  as 
follows:  (1)  The  leg  is  displaced  inward,  the  weight  of  the  body 
therefore  falling  on  the  inner  side  of  the  foot.  (2)  The  leg  is  rotated 
so  that  a  perpendicular  line  dropped  from  the  crest  of  the  tibia,  instead 
of  falling  through  the  second  toe  falls  inside  the  great  toe,  or  even 
over  the  centre  of  the  internal  border  of  the  foot.  The  leg  has  thus 
a  tendency  to  slip  downward  and  inward  from  off  the  foot,  the  astraga- 
lus slipping  downward  and  inward  from  off  the  os  calcis  until  its 
movement  is  checked  by  the  calcaneonavicular,  deltoid,  and  inter- 
osseous ligaments.  As  this  tendency  progresses  to  deformity  the 
supporting  ligaments  become  stretched  and  the  muscles  weakened,  so 
that  an  actual  subluxation  of  the  astragalus  is  present.  Thus  the 
picture  of  the  advanced  deformity,  the  real  "flat-foot,"  is  as  follows: 
The  arched  part,  or  waist  of  the  foot  appears  much  broader  than 
normal,  the  heel  projects,  the  external  malleolus  is  much  less  promi- 
nent than  normal;  the  internal  malleolus  is  much  more  so,  and  with 
the  astragalus  overhangs  the  bearing  surface  of  the  sole. 

The  condition  is  frequently  encountered  in  childhood,  but  rarely 
then  gives  rise  to  symptoms,  on  account  of  the  relative  insignificance 
of  the  child's  weight,  the  symptom  usually  developing  later  under 
the  greater  strain  of  increased  weight  and  regular  occupation.  The 
disability  is  most  commonly  encountered  between  the  ages  of  ten 
and  thirty,  is  slightly  more  common  in  males  than  females,  and  is 
favored  by  occupations  that  induce  a  persistence  of  the  passive  atti- 
tude, such  as  barkeepers,  waiters,  cooks,  and  shop  assistants. 

Symptoms. — The  symptoms  begin  as  a  feeling  of  weakness,  the 
patient  gradually  recognizing  a  persistent  sensation  of  discomfort,  tire, 
and  strain  about  the  inner  side  of  the  foot  and  ankle ;  sometimes  after 
long  standing  a  dull  ache  in  the  calf  of  the  leg,  or  pain  in  the  knee, 
hip,  or  lumbar  region.  After  a  time  he  realizes  that  he  is  accommodat- 
ing his  habits  to  his  feet — that  he  rides  where  he  once  walked,  sits  where 
he  once  stood,  that  his  feet  have  lost  their  spring,  that  his  gait  is 
slouchy,  that  he  cannot  get  comfortable  shoes;  and  that  he  finally 
speaks  of  himself  as  having  a  weak  ankle,  gout,  or  rheumatism.  As  a 
rule,  actual  pain  is  felt  only  when  the  foot  is  in  use,  and  it  must  be 
remembered  that  pain  is  a  symptom  of  strain,  injury,  and  progressive 
deformity.  Thus  it  may  be  encountered  before  deformity  can  be 
demonstrated,  and  be  absent  after  deformity  is  established. 


FLAT-FOOT 


977 


Diagnosis. — Diagnosis  should  be  made  on  the  basis  of  an  orderly 
examination.  (1 )  Examine  the  attitudes  of  standing  and  walking,  look 
for  the  heel  walk,  the  slouchy  gait,  and  the  exaggerated  turning  out 
of  the  feet.  (2)  The  distribution  of  weight  and  strain  is  often  shown 
by  the  wearing  off  of  the  inner  border  of  the  shoe,  and  the  bulging  of 
the  inner  side  of  the  sole.  The  line  dropped  from  the  erest  of  the  tibia, 
as  before  mentioned,  falls  inside  the  great  toe.  (3)  The  slight  con- 
cavity that  should  be  present  between  the  toes  and  heels  when  the 
feet  are  placed  in  apposition  is  replaced  by  a  convexity  when  weight 
is  borne.  (4)  Restriction  of  the  normal  range  of  active  and  passive 
motion,  particularly  that  of  adduction  or  inversion  of  the  foot.  (5) 
Tracing  of  the  bearing  surface  of  the  foot,  and  the  comparison  of  its 
size  and  shape  with  that  of  the  normal.    This  test  is  of  the  least  value. 


Fig.  497. — Flat-foot  of  extreme  grade.     (Lovett.) 


Treatment. — Treatment  aims  at  the  restoration  of  function,  which 
must  be  accomplished  by  the  correct  application  of  the  patient's 
muscular  power.  All  bars  to  that  application,  therefore,  such  as 
deformity,  pain,  adhesions,  or  contractions,  must  previously  be 
removed.  In  the  ordinary  cases  the  routine  treatment  is  as  follows: 
(1)  Providing  the  patient  with  a  proper  shoe,  and,  as  a  rule,  raising 
the  inner  border  of  the  heel  and  sole  a  quarter  of  an  inch,  enough 
to  throw  the  weight  on  the  outer  border  of  the  foot.  (2)  Calling  the 
patient's  attention  to  the  improper  attitudes  that  he  has  been  assum- 
ing, showing  him  that  he  must  at  all  times  try  to  throw  his  weight  on 
the  outer  border  of  his  feet,  that  he  must  place  his  feet  parallel  to  one 
another  in  walking,  try  to  press  down  the  sole  of  his  shoe  with  his 
toes,  and  to  employ  the  lift  of  the  calf  muscle  by  fully  extending  his 
leg  and  raising  his  body  on  his  foot.  (3)  Giving  the  patient  exercises 
61 


978  DEFORMITIES  AND   THEIR  CORRECTION 

devoted  to  strengthening  the  museles  of  adduction  and  plantar  flexion 
— thus  continually  adducting  and  inverting  the  foot  at  every  oppor- 
tunity. Also  rising  on  tiptoe  and  sinking  slowly,  throwing  the  weight 
on  the  outer  borders  of  the  feet  should  be  done  from  twenty  to  one 
hundred  times  a  day.  He  should,  however,  be  impressed  with  the 
fact  that  the  best  of  all  exercises  is  the  proper  walk.  (4)  If  the  patient 
is  not  able  voluntarily  to  prevent  deformity,  a  brace  will  be  necessary 
to  hold  the  foot  in  proper  position  and  prevent  discomfort.    This  brace 


Fig.   498. — The  outlines  of  Dr.    Whitman's  brace:    A,  the   astragalonavicalur  articu- 
lation, the  highest  part  of  the  arch. 

differs  from  the  useless  supports,  plates,  pads,  springs,  etc.,  that  are 
commonly  applied,  in  that  those  who  apply  such  treatment  regard 
the  deformity  as  a  direct  breaking  down  of  the  arch.  As  has  been 
shown,  this  is  not  the  case,  the  deformity — except  in  rare  cases  of 
true  "pes  planus,"  where  the  foot  is  flat  without  pain  and  without  ab- 
duction— being  a  compound  one  of  lateral  deviation  and  sinking. 
Therefore  the  brace  required  to  correct  it  is  one  that  will  prevent 
both  factors  in  its  production,  and  hold  the  foot  laterally  as  well  as 
support  the  arch,  while  it  does  not  interfere  with  the  normal  move- 


Fig.  499. — Shows  the  under  surface  of  the  brace  and  the  outer  flange:    B,  the  calcaneo- 
cuboid articulation;    C,  the  extremity  of  the  fifth  metatarsal  bone. 

ments  of  the  foot,  thereby  allowing  the  increase  of  muscular  strength 
and  ability  on  which  cure  depends. 

It  is  impossible  in  this  space  fully  to  describe  the  methods  of  making 
and  fitting  the  brace.  The  accompanying  illustration  will  give  some 
idea  of  its  shape  and  the  method  by  which  it  is  fitted.  It  should  be 
emphasized,  however,  that  in  taking  the  plaster  cast  of  the  foot  on 
which  the  brace  is  fitted  that  the  foot  should  be  in  the  corrected  posi- 
tion (adduction)  and  that  a  mere  impression  of  the  sole  as  the  patient 


HALLUX  VALGUS  979 

stands  is  useless.  It  should  also  he  understood  that  it  is  useless  to 
apply  a  hrace  to  a  rigid,  deformed,  or  painful  foot.  Such  feet  must 
first  he  treated  by  stretching  and  adhesive-plaster  strapping  until 
they  are  practically  painless,  until  deformity  is  overcome  and  active 
motion  is  possible,  when  the  brace  may  then  be  applied.  Some  feet 
are  so  rigid  and  so  painful  that  they  can  only  be  stretched  under  an 
anesthetic.  They  should  then  be  placed  in  plaster  of  Paris  in  the  over- 
corrected  position,  and  allowed  to  remain  there  for  about  a  month, 
during  which  time  the  patient  is  encouraged  to  walk  about.  The  cast 
is  then  removed,  and  the  patient  treated  as  the  mobility  of  his  foot 
indicates. 

In  conclusion  two  points  should  again  be  emphasized:  (1)  that 
weak-foot  in  all  its  grades  is  characterized  by  the  persistent  attitude 
of  abduction,  which  attitude  must  be  corrected  if  cure  is  to  be 
accomplished;  (2)  that  the  depth  of  the  arch  is  of  minor  importance 
in  comparison  with  the  other  symptoms  and  physical  signs. 

Hallux  Valgus.— This  condition,  which  consists,  in  an  outward  devia- 
tion of  the  great  toe,  is  fairly  common  in  individuals  past  middle  life. 
It  may  be  congenital  or  even  hereditary,  but  in  the  great  majority 
of  instances  it  is  caused  by  an  ill-fitting  shoe  which  either  compresses 
the  toes,  or,  by  being  too  short,  forces  the  prominent  great  toe  to  one 
side. 

In  extreme  cases  the  toe  may  lie  transversely  across  the  other 
toes,  in  contact  with  their  dorsal  surfaces.  This  produces  a  sub- 
luxation of  the  metatarsophalangeal  joint,  the  head  of  the  metatarsal 
bone  making  a  projection  on  the  inner  side  of  the  foot,  and  by  friction 
of  the  shoe  may  become  enlarged  by  the  growth  of  an  exostosis.  A 
bursa  forms  between  the  head  of  the  bone  and  the  soft  parts,  which 
may  become  inflamed,  forming  a  bunion.  This  may  suppurate,  and 
give  rise  to  a  more  or  less  extensive  cellulitis  of  the  foot,  a  suppurative 
arthritis,  and  occasionally  osteomyelitis  of  the  metatarsal  bone. 

In  the  late  suppurative  condition  just  described,  the  treatment  should 
consist  in  incision  and  drainage,  with  excision  of  the  joint  and  removal 
of  the  dead  bone  if  necessary.  The  early  or  minor  grades  of  deformity 
may  be  corrected  by  means  of  a  proper  shoe,  by  splinting  the  toe  at 
night,  and  by  the  use  of  the  Holden  toe-post.  This  is  a  thin  piece  of 
metal  fixed  upright  in  an  inner  sole,  so  that  it  separates  the  first  and 
second  toes,  and  holds  the  former  in  an  improved  position.  In  this, 
of  course,  a  special  shoe  and  a  digitated  stocking  are  necessary.  When 
the  deformity  is  more  marked  operation  will  be  necessary.  The  inner 
aspect  of  the  metatarsophalangeal  joint  is  approached  by  a  longitu- 
dinal or  U-shaped  incision.  The  bursa  is  dissected  free  from  the  bone, 
from  below  upward,  leaving  the  upper  margin  attached  to  the  phalanx. 
The  joint  is  next  opened  and  the  deformity  removed  by  excision  of 
the  exostoses  or  by  complete  resection.  The  free  bursa  is  then  inter- 
posed between  the  ends  of  the  bones  and  held  in  place  by  a  catgut 
suture.    The  external  wound  is  next  closed,  the  position  of  the  toe 


980  DEFORMITIES  AND   THEIR  CORRECTION 

overcorrected  by  means  of  a  triangular  pad  placed  between  it  and  the 
second  toe,  and  a  sterile  dressing  applied. 

In  cases  of  extreme  deformity  the  end  of  the  metatarsal  bone 
should  be  excised,  preferably  by  the  method  suggested  by  Fowler.  This 
consists  in  making  an  incision  between  the  first  and  second  toes,  open- 
ing the  joint  from  the  inside,  strongly  adducting  the  toe,  and  exposing 
the  head  of  the  metatarsal  bone  in  the  wound,  removing  the  articular 
surface  with  bone-forceps  or  a  saw,  replacing  the  toe,  and  suturing  the 
wound.  After  healing  of  the  wound  the  toe  should  be  maintained  in 
proper  position  by  a  plantar  splint  of  gutta-percha  for  several  weeks. 

Hammer-toe. — Hammer-toe  is  a  contraction  of  the  second,  third, 
or  fourth  toe,  resulting  in  an  acute  flexion  of  the  second  phalanx  and 
generally  full  extension  of  the  third.  This  condition  is  frequently 
accompanied  by  an  irritable  callosity  over  the  summit  of  the  flexed 
joint,  and  may  be  exceedingly  painful.  In  the  earlier  stages  the  deform- 
ity sometimes  may  be  corrected  by  the  use  of  splints  or  tenotomy; 
in  the  latter  stages,  however,  excision  of  the  interphalangeal  joint  or 
amputation  at  the  metatarsophalangeal  joint  is  to  be  recommended. 

Anterior  Metatarsalgia. — This  affection  was  first  accurately  described 
by  Morton,  of  Philadelphia,  and  is  often  spoken  of  as  Morton's  painful 
joint.  It  consists  in  the  occurrence  of  a  severe  and  often  spasmodic 
pain  between  the  heads  of  the  second  and  third,  third  and  fourth,  or 
fourth  and  fifth  metatarsal  bones.  The  pain  usually  comes  on  during 
walking,  and  generally  is  relieved  by  rest  and  removing  the  shoe. 
Exceptionally  it  occurs  during  rest,  and  may  give  rise  to  great  suffering. 
It  is  often  associated  with  weak  foot,  and  has  also  been  found  to  be 
accompanied  by  a  breaking  down  of  the  anterior  transverse  arch. 

Treatment. — The  treatment  should  consist  in  the  wearing  of  prop- 
erly made  shoes  which  do  not  compress  the  toes,  and,  if  the  transverse 
arch  is  broken  down  or  rigid,  a  support  should  be  fitted  to  correct 
this  deformity. 

Club-hand. — Club-hand  is  an  exceedingly  rare  condition  of  the  upper 
extremity  analogous  to  club-foot  in  the  lower.  The  deformity  may 
or  may  not  be  associated  with  abnormalities  of  the  bony  skeleton.  As 
a  rule,  the  hand  is  deflected,  either  in  flexion  or  extension,  toward  the 
radial  or  ulnar  side  of  the  forearm.  It  is  not  infrequently  associated 
with  other  congenital  malformations. 

At  an  early"  period  after  birth  the  deformity  may  often  be  cor- 
rected by  manipulation  and  fixation  with  splints.  Tenotomy  or 
osteotomy  may  be  required,  and  amputation  is  occasionally  indicated. 
The  results  of  tenotomy  in  the  hand  are  less  satisfactory  than  in  the 
lower  extremity,  for  the  reason  that  failure  of  union  often  occurs, 
with  consequent  impairment  of  motion. 

Webbed  Fingers  (Syndactylism). — Webbed  fingers  is  a  congenital 
malformation  in  which  two  or  more  of  the  fingers  are  joined  by  either  a 
thin  cutaneous  bridge  or  by  a  thick,  fleshy  mass.  When  the  bridge 
is  thin,  it  may  be  pierced  at  the  base  of  the  fingers  and  the  opening 


TRIGGER-FINGER 


981 


allowed  to  heal,  after  which  the  thin  bridge  may  be  divided  by  scissors 
or  a  scalpel.  If  the  bridge  is  thick,  two  cutaneous  flaps  should  be 
raised,  one  from  the  palmar  surface  of  one  finger  and  another  from  the 
dorsal  surface  of  the  adjoining  digit.  After  these  flaps  are  dissected 
free  the  bridge  of  tissue  is  removed  and  the  exposed  surface  of  each 
finger  covered  by  wrapping  it  with  its  own  cutaneous  flap,  which 
is  trimmed  to  fill  exactly  the  freshened  area,  and  sutured  in  place 
(Fig.  500). 

Supernumerary  Fingers  (Polydactylism). — Occasionally  children  are 
born  with  a  complete  or  incomplete  sixth  digit.  The  malformation  is 
frequently  present  in  both  hands.  If  useless  or  disfiguring,  the  extra 
finger  should  be  removed.  A  similar  condition  is  seen  occasionally  in 
the  lower  extremitv.. 


Fig.  500. — Webbed  fingers.     (Stimson.) 


Trigger-finger. — Trigger-finger  is  a  condition  in  which  the  patient 
is  able  to  close  the  fist,  but  on  attempting  to  open  it  one  finger  remains 
for  a  fraction  of  a  second  flexed,  and  then  flies  open  with  a  jerk,  or  is 
only  opened  by  pressure  of  one  of  the  other  fingers,  in  which  case  it  is 
extended  in  the  same  spasmodic  manner. 

The  cause  of  the  affection  is  some  interference  with  the  smooth 
and  even  gliding  of  the  tendon  in  its  sheath,  as  a  small  fibroma  or  other 
tumor.  In  a  case  operated  upon  by  Lilienthal  the  cause  of  the  trouble 
was  found  to  be  a  minute  cyst  in  the  interior  of  the  tendon  sheath. 

Treatment. — The  treatment  should  consist  in  opening  the  sheath  and 
removal  of  the  cause. 


INDEX. 


Abdomen,  cellulitis  of,  507 
contusions  of,  500 
diagnosis  of,  501 
treatment  of,  502 
diseases  of,  507 
injuries  of,  500 

extraperitoneal,  500 
intraperitoneal,  500 
wounds  of,  504 

non-penetrating,  504 
penetrating,  504 

symptoms  of,  504 
treatment  of,  505 
Abdominal  aorta,  ligation  of,  274 

distention    following    mechanical 
ileus,  186 
mild,  treatment  of,  183 
paralytic  ileus  and,  185 
severe,  treatment  of,  183 
treatment  of,  181 

prophylactic,  during  oper- 
ation, 182 
post-operative,  182 
organs,  actinomycosis  of,  70 
wall,  angioma  of,  507 

dermoid  cysts  of,  507 
desmoids  of,  508 
epithelioma  of,  507 
fibroneuroma  of,  507 
lipoma  of,  507 
sarcoma  of,  507 
tumors  of,  507 
Abnormalities,  congenital,  of  kidney,  600 
Abrasion  of  skin,  229 
Abscess,  acute,  definition  of,  35 
in  acute  general  sepsis,  39 
alveolar,  433 
of  anterior  closed  space,  distal,  208 

middle,  212 
appendicular,  560 
at  base  of  fingers,  212 
bone,  741 

tuberculous,  751 
of  brain,  362 
of  chest-wall,  462 
chronic,  definition  of,  37 
of  hypothenar  eminence,  220 
ischiorectal,  724 
of  kidney,  614 
of  liver,  571 


Abscess,  lumbar,  789 

of  lung,  470 

of  palm  of  hand,  212 

of  parotid  gland,  390 

of  pericardium,  242 

perinephritic,  616 

peritonsillar,  432 

of  proximal  closed  space,  212 

psoas,  789 

diagnosis     of,     from      femoral 
hernia,  932 

retropharyngeal,  432,  789 

of  scalp,  332 

of  spleen,  596 

subcutaneous,  197 
treatment  of,  198 

submammary,  484 

subperiosteal,  742 

subphrenic,  appendicitis  and,  568 

of  subungual  space,  205 

of  thenar  eminence,  220 

at  web  of  fingers,  212 
Accessory  sinuses,  diseases  of,  422 

spleen,  596 
Acidosis,  116 

Cheyne-Stokes,  respiration  in,  119 

coma  in,  119 

convulsions  in,  119 

cyanosis  in,  119 

delirium  in,  119 

in  diabetics,  117 

dyspnea  in,  119 

jaundice  in,  119 

nausea  in,  1 19 

in  non-diabetics,  118 
symptoms  of,  118 

post-anesthetic,  118 

symptoms  of,  119 

treatment  of,  119 

vomiting  in,  119 
Acinous  carcinoma  of  breast,  492 
Acromegaly,  755 

symptoms  of,  755 

treatment  of,  755 
Acromial  end  of  clavicle,  dislocations  of, 

878 
Acromion  process  of  scapula,  fracture  of, 

826 
Actinomycosis,  68 

of  abdominal  organs,  70 

of  bone,  752 

of  brain,  72 


984 


INDEX 


Actinomycosis,  etiology  of,  G8 

of  face,  69 
.    of  lung,  472 

of  neck,  69 

pathologic  anatomy  of,  69 

of  peritoneum,  518 

of  skin,  72,  228 

Streptothrix  actinomyces  in,  68 

symptoms  of,  69 

of  thorax,  70 

treatment  of,  72 
Actinomycotic  ulcers  of  rectum,  729 
Acupunture  in  aneurism,  259 
Adam's    forceps    in    fractures    of    nasal 

bones,  821 
Adenitis,    femoral,    diagnosis    of,    from 

femoral  hernia,  932 
Adenocarcinoma,  92 

of  bladder,  665 
Adenocele  of  breast,  490 
Adenoid  growths,  429 

treatment  of,  429 
Adenoma,  87 

of  intestine,  550 

of  kidney,  627 

of  liver,  574 

of  palate,  436 

of  rectum,  730 

of  testicle,  705 

of  trachea,  448 
Adenomatous  goitre,  400,  401 
Adenopapilloma  of  breast,  intracanalic- 

ular,  490 
Adrenal  gland,  cysts  of,  629 

symptoms  of,  630 
treatment  of,  630 
hypernephroma  of,  629 
sarcoma  of,  629 
tumors  of,  629 
Agglutinins,  29 
Aggressins,  25 
Ainhum  of  skin,  229 
Albert's  disease,  302 
Alcoholics,  surgical  risk  in,  114 
Alcoholism,  shock  and,  104 
Alexins  in  acute  inflammation,  32 
Alveolar  abscess,  433 
Amastia,  483 

Ammonium  urate  calculi,  657 
Amputations,  944 

at  ankle-joint,  961 

of  arm,  955 

Brewer's  tourniquet  in,  945 

circular  method  of,  949 

at  elbow-joint,  954 

of  fingers,  952 

general  considerations  of,  944 

handling  of  tissues  during,  946 

hemostasis  in,  945 

at  hip-joint,  957 

interscapulothoracic,  956 

kinetic  stump  in,  947 

at  knee-joint,  959 

of  leg,  961 


Amputations,  making  of  flaps  in,  947 
of  metatarsophalangeal  joints,  963 
postoperative  treatment  of,  951 
preparation  for,  945 
racket-shaped  method  of,  951 
at  shoulder-joint,  955 
site  of,  944 

skin-Map  method  of,  949 
skin-   and    muscle-flap    method   of, 

950 
Teale's  method  of,  950 
of  thigh,  959 
time  for,  944 
of  toes,  963 
in  tuberculosis  of  hip,  796 

of  joints,  787 
at  wrist,  954 
Anastomosis,  lateral,  557 
by  Murphy  button,  555 
of  nerves,  318 
Anatomical  neck  of  humerus,  fracture 

of,  831 
Anemia  in  carcinoma  of  stomach,  532 
pernicious,  598 

in    tuberculosis   of   cervical   lymph 
nodes,  286 
Anesthesia,  153 

endopharyngeal  insufflation,  162 
general,  153 

chloroform,  164 

ether,  156 

colonic  absorption  of,  167 

nitrous  oxide,  154 
intratracheal  insufflation,  161 

indications  for,  161 
intravenous,  166 
local,  168 

infiltration,  169 

regional  method,  170 

spinal,  170 

surface  application,  168 

venous,  171 
in  wounds  of  nerve  trunks,  304 
Anesthetic  shock,  treatment  of,  168 
Anesthetometer,  Connell's,  163 
Aneurism,  249 

acupuncture  in,  259 

aphonia  in,  252 

arteriovenous,  250 

of  bone,  763 

cirsoid,  249 

compression  in,  253 

development  of,  249 

diagnosis  of,  251 

dissecting,  249 

dysphagia  in,  252 

dyspnea  in,  252 

edema  in,  253 

endo-aneurysmorrhaphv  in,  258 

false,  123,  249 

fusiform,  249 

galvanopuncture  in,  259 

ligature  in,  256 

miliar}',  249 


INDEX 


985 


Aneurism  needle,  2G9 
pain  in,  252 
paralysis  in,  252 

pulse  in,  253 
of  renal  artery,  605 
rupture  of,  251,  252 
saeeulated,  249 
shock  in,  253 
syncope  in,  253 
syphilis  and,  249 
thoracic,  251 
traumatic,  249 

fractures  and,  812 
treatment  of,  253 

non-operative,  253 
operative,  254 
true,  249 
varicose,  251 
Aneurismal  varix,  250 
Angina  Ludovici,  390 

symptoms  of,  390 
treatment  of,  390 
Angioma,  84 

of  abdominal  wall,  507 
of  brain,  368 
cavernous,  85 

of  spleen,  599 
of  jaws,  436 
of  kidney,  627 
of  mouth,  436 
of  pharynx,  436 
pulsating,  252 
of  rectum,  730 
telangiectoides,  85 
Ankle,  dislocations  of,  905 
tuberculosis  of,  798 
symptoms  of,  798 
treatment  of,  798 
Ankle-joint,  acute  traumatic  arthritis  of, 
773 
amputation  at,  961 

Hey's  operation  for,  963 
Lisfranc's  amputation  for,  963 
Pirogoff  s  operation  for,  961 
Roux's  operation  for,  962 
Skey's  operation  for,  963 
Syme's  operation  for,  961 
tuberculous  arthritis  of,  798 
Ankylosis  of  joints,  804 
Anoci-association,  172 

in  shock,  109 
Anomalies  of  renal  artery,  600 

of  thyroid  gland,  398 
Anterior  closed  spaces,  201 

distal,  abscess  of,  208 

treatment  of,  209 
with    osteomyeli- 
tis     of      distal 
phalanx,  210 
middle,  abscess  of,  212 
tibial  artery,  ligation  of,  276 
Anthrax,  47 

Bacillus  anthracis  and,  47 
etiology  of,  47 


Anthrax,  external,  47 

of  face,  391 

internal,  47 

intestinal,  47 

respiratory,  48 

symptoms  of,  47 

treatment  of,  48 
Antisepsis,  128 
Antitoxins,  29 
Anuria  calculus,  623,  626 
Anus,  congenital  malformations  of,  723 

disfases  of,  723 

fissures  of,  729 

symptoms  of,  729 
treatment  of,  729 

injuries  of,  723 

imperforate,  723 

pruritus  of,  729 

treatment  of,  730 
Aorta,  abdominal,  ligation  of,  274 
Aphasia,    motor,    in    tumors   of    brain, 

369 
Apoplexy,  cerebral,  123 

pancreatic,  589 
Appendectomy,  intermuscular,  564 
Appendicitis,  559 

acute  catarrhal,  559 
interstitial,  560 
perforative,  560 
sequela?  of,  568 

chronic,  566 

course  of,  562 

diagnosis  of,  562 

fecal  fistula  and,  569 

fever  in,  561 

gangrenous,  560 

^Ic•Burney's  operation  for,  564 
point  in,  560,  562 

nausea  in,  561 

pain  in,  561 

portal  thrombosis  and,  568 

pulse  in,  561 

recurrent,  559 

relapsing,  559 

subphrenic  abscess  and,  568 

symptoms  of,  560 

treatment  of,  563 

postoperative,  567 

ventral  hernia  and,  569 

vomiting  in,  561 
Appendicular  abscess,  560 

colic,  559 

dyspepsia,  566 
Appendix,  empyema  of,  562 

inflammation  of,  559 
Arm,  amputation  of,  955 

test  in  tetany,  413 
Arnold  sterilizer,  132 
Arterial  hemorrhage,  123 
Arteriovenous  aneurism,  250 
Arteritis,  acute,  248 

atheromatous,  248 

chronic,  248 

obliterative,  248 


980 


INDEX 


Artery  or  arteries,  abdominal  aorta,  liga- 
tion of,  274 
axillary  ligation  of,  272 
brachial,  ligation  of,  273 
carotid,  common,  ligation  of,  270 
external,  ligation  of,  271 
internal,  ligation  of,  271 
dorsalis  pedis,  ligation  of,  277 
facial,  ligation  of,  271 
femoral,  common,  ligation  of,  275 

superficial,  ligation  of,  275 
gluteal,  ligation  of,  275 
iliac,  common,  ligation  of,  274 
external,  ligation  of,  275 
internal,  ligation  of,  274 
innominate,  ligation  of,  270 
ligation  of,  268 
lingual,  ligation  of,  271 
occipital,  ligation  of,  271: 
peroneal,  ligation  of,  277 
popliteal,  ligation  of,  276 
radial,  ligation  of,  273 
sciatic,  ligation  of,  275 
subclavian,  ligation  of,  271 
temporal,  ligation  of,  271 
thyroid,  inferior,  ligation  of,  272 

superior,  ligation  of,  271 
tibial,  anterior,  ligation  of,  276 

posterior,  ligation  of,  276 
ulnar,  ligation  of,  273 
vertebral,  ligation  of,  272 
Arthritis,  772 
acute,  772 

infective,  773 

arthrotomy  in,  775 
diplococcus  in,  774 
etiology  of,  773 
gonococcus  in,  774 
pathology  of,  773 
pneumococcus  in,  774 
staphylococcus  in,  774 
streptococcus  in,  774 
symptoms  of,  773 
treatment  of,  775 
varieties  of,  774 
traumatic,  772 

ankle-joint  in,  773 
effusion  in,  772 
elbow-joint  in,  772 
hip-joint  in,  772 
knee-joint  in,  773 
pain  in,  772 
shoulder-joint  in,  772 
symptoms  of,  772 
treatment  of,  773 
wrist-joint  in,  772 
ankylopoitica,  777 
chronic,  776 

course  of,  780 
etiology  of,  777 
pain  in,  779 
pathology  of,  777 
primary  hypertrophic,  782 
treatment  of,  782 


Arthritis,  chronic,  symptoms  of,  778 
treatment  of,  780 

local,  781 
ulcerative,  782 
villous,  782 

etiology,  782 
treatment  of,  782 
x-rays  in,  780,  781 
deformans,  777 

in  children,  782 

etiology  of,  782 
symptoms  of,  782 
treatment  of,  782 
gouty,  776 

infective,  secondary,  776 
rheumatoid,  777 
senile,  782 

suppurative,      of       interphalangeal 
joints,  211 
of   metacarpophalangeal   joint, 
211 
syphilitic,  782 

symptoms  of,  783 
treatment  of,  783 
tuberculous,  783 

of  ankle-joint,  798 
of  elbow,'  800 
of  hip-joint,  794 
of  knee-joint,  796 
pain  in,  785 
pathology  of,  784 
of  shoulder,  799 
symptoms  of,  785 
toxemia  in,  785 
treatment  of,  786 

operative,  787 
of  wrist,  800 
Arthrodesis,  805 
Arthropathy,  neuropathic,  801 
symptoms  of,  802 
treatment  of,  802 
Arthrotomy  in  acute  infective  arthritis, 
775 
in  tuberculosis  of  joints,  787 
Articulations,  carpometacarpal,  disloca- 
tions of,  894 
inferior  radio-ulnar,  dislocations  of, 

892 
mediocarpal,  dislocations  of,  893 
radiocarpal,  dislocations  of,  893 
Artificial  limbs,  use  of,  952 

pneumothorax,  477 
Ascending  infections  of  kidney,  608 

spiral  bandage,  134 
Ascites,  chylous,  278 

cirrhosis  of  liver  and,  surgical  treat- 
ment of,  574 
Asepsis,  128 

Aspiration  of  pericardium,  243 

Astereognosis  in  tumors  of  brain,  369 

Astragalus,  dislocations  of,  907 

forward,  907 

outward,  907 

treatment  of,  907 


INDEX 


987 


Astragalus,  fractures  of,  870 

diagnosis  of,  871 
Asymmetrical  goitre,  400 
Ataxia  in  tumors  of  brain,  369 
Atheromatous  arteritis,  248 

dermoid  cysts  of  skin,  235 
Atlas  of  spine,  fracture  of,  378 
Atony  of  bladder,  671 
Atrophy,  hernia  and,  913 

of  skin  in  varicose  veins,  264 
Auditopsychic  area  of  brain,  347 
Auditosensory  area  of  brain,  347 
Autoclave,  steam,  132 
Avulsion  of  scalp,  330 
Axillary  abscess  of  chest-wall,  463 

artery,  ligation  of,  272 
Axis  of  spine,  fracture  of,  378 


B 


Bacillus    aerogenes    capsulatus    infec- 
tions, 50 
diagnosis  of,  51 
treatment  of,  51 

anthracis,  anthrax  and,  47 

gas,  50 

of  glanders,  49 

of  malignant  edema,  48 

mallei,  50 

tuberculosis,  58 
Backache  following     operations,     treat- 
ment of,  179 
Bacteria,  action  of,  in  body,  27 

of  bronchi,  22 

of  genito-urinary  tract,  23 

infection  with,  external  sources,  19 
internal  sources,  21 
portals  of  entry  of,  19 

inflammation  of  joints  and,  771 

of  intestines,  22 

of  larynx,  22 

of  mouth,  21 

of  pharynx,  21 

of  respiratory  passages,  21 

of  skin,  20 

of  stomach,  22 
Bacterial  excitant,  25 

host,  26 
Bacteriuria,  652 

symptoms  of,  653 

treatment  of,  653 
Balanitis,  688 
Balanoposthitis,  688 
Bandage,  ascending  spiral,  134 

figure-of-eight,  134 

handkerchief,  139 

many-tailed,  139 

modified  Velpeau,  137 

plaster-of-Paris,  142 

recurrent,  136 

roller,  134 

spica,  134 

spiral  reversed,  134 


Bandage,  T-,  139 
triangular,  139 
two-tailed  jaw,  141 
Bandaging,  133 
Basal-celled  epithelioma,  193 
Basedow's  disease,  404 
Bassini's  operation  for  inguinal   hernia, 

925 
Bed-sores,  57 
Bennett  inhaler,  160 
Bigelow  lithotrite,  660 
Bilharzia  hematoma,  hematuria  and,  654 
Biliary  passages,  diseases  of,  575 
Binder,  breast,  138 
"Birth  marks,"  267 
Bladder,  adenocarcinoma  of,  665 
atony  of,  671 
carcinoma  of,  665 
congenital  malformations  of,  646 
contusions  of,  647 
diseases  of,  650 
diverticula  of,  647 
double,  647 
epithelioma  of,  665 
exstrophy  of,  646 

treatment  of,  647 
fibromyxoma  of,  665 
foreign  bodies  in,  650  . 

treatment  of,  650 
functional  affections  of,  670 
inflammation  of,  650 
injuries  of,  647 

implantation  of  ureter  into,  645 
painful  neuroses  of,  671 

treatment  of,  672 
papilloma  of,  665 
paralysis  of,  671 
rupture  of,  648 
shock  in,  648 
symptoms  of,  648 
treatment  of,  649 
sarcoma  of,  665 

stone  in,  657.     See  Vesical  calculus, 
trabeculated,  681,  711 
tuberculosis  of,  655 
cystoscopy  in,  656 
diagnosis  of,  656 
nephrectomy  in,  656 
pain  in,  656 
symptoms  of,  655 
treatment  of,  656 
tumors  of,  664 

cystitis  in,  666 
diagnosis  of,  666 
dysuria  in,  665 
hematuria  in,  665 
pain  in,  665 
prognosis  of,  666 
suprapubic  lithotomy  in,  666 
symptoms  of,  665 
treatment  of,  666 
urine  in,  665 
villous,  665 
wounds  of,  647 


INDEX 


Blake's  operation  for  femoral  hernia,  933 
for  inguinal  hernia,  928 
for  umbilical  hernia,  937 
Blastomycetes,  72 
Blastomycosis,  72 
of  skin,  228 
treatment  of,  73 
Bleeders,  definition  of,  123 
Blood,  transfusion  of,  149 
Bloodgood's  operation  for   inguinal   her- 
nia, 927,  929 
Blood-pressure  in  compression  of  brain, 
3.55 
in  shock,  102 
Bloodvessels,  diseases  of,  248 
fatty  degeneration  of,  248 
hernia  and,  911 
inflammation  of,  248 
media  of,  calcification  of,  248 
tumor  of,  249.     See  Aneurism, 
wounds  of,  248 
Boas-Oppler   bacillus    in    carcinoma    of 
stomach,  532 
in  pyloric  stenosis,  529 
Bodv  of  scapula,  fracture  of,  827 
Boils,  194 

Bone  or  bones,  actinomycosis  of,  752 
treatment  of,  753 
aneurism  of,  763 
carcinoma  of,  765 
caries  of,  753 
carpal,  dislocations  of,  893 

fractures  of,  850 
chondroma  of,  758 
cranial,  syphilis  of,  343 
tuberculosis  of,  343 
cysts  of,  760 

symptoms  of,  760 
treatment  of,  760 
degeneration  of,  756 
diffuse  periosteal  thickening  of,  753 
diseases  of,  741 
of  face,  fractures  of,  820 
fibroma  of,  760 
of  foot,  fractures  of,  870 
gangrene  of,  753 
of  hand,  dislocations  of,  894 
hypertrophy  of,  755 
inflammation  of,  741 
sequelae  of,  753 
lipoma  of,  760 

of  lower  extremity,  fractures  of,  852 
metatarsal,  dislocations  of,  907 

fractures  of,  871 
myeloma  of,  762 

multiple,  765 
nasal,  fractures  of,  820 
necrosis  of,  753 
nutritive  disturbances  of,  753 
osteoma  of,  758 
Paget's  disease  of,  754 
sarcoma  of,  760 
central,  761 
diagnosis  of,  763 


Bone  or  bones,  sarcoma  of,    medullary 
761 

periosteal,  761 
peripheral,  761 

prognosis  of,  764 
treatment  of,  764 

.c-iays  in,  761 
sclerosis  of,  753 
semilunar,  dislocations  of,  893 
syphilis  of,  749 

pain  in,  750 

symptoms  of,  750 

treatment  of,  750 
tarsal,  dislocations  of,  907 
of  trunk,  fractures  of,  823 
tuberculosis  of,  751 

symptoms  of,  751 

treatment  of.  751 

x-rays  in,  751 
tumors  of,  758 
ulceration  of,  753 

of   upper  extremities,  fractures    of, 
826 
Bone-abscess,  741 

tuberculous,  751 
Bougie,  bulbous,  684 

olive-pointed,  684 
Bowel,  obstruction  of,  550 
strangulation  of,  550 
ulcers  of,  544.     See  Intestine,  ulcers 
of. 
Bow-legs,  971 

diagnosis  of,  972 
treatment  of,  973 
Brachial  artery,  ligation  of,  273 
nerves,  paralysis  of,  320 

operations  for,  320 
Bradford  frame  in  Pott's  disease,  791 
Brain,  344 

abscess  of,  362 

course  of,  362 

symptoms  of,  362 

treatment  of,  363 
actinomycosis  of,  72 
angioma  of,  368 
areas  of,  346,  347 

auditopsychia,  347 

auditosensory,  347 

motor,  346 

olfactory,  348 

postcentral.  347 

precentral.  34tj 

visuopsychic,  347 

visuosensory,  347 
compression  of,  354 

blood-pressure  in,  355 

Chevne-Stokes    respiration    in, 
355 

paralysis  in,  355 

prognosis  of,  355 

pulse  in,  355 

treatment  of,  355 
concussion  of,  352 

diagnosis  of,  353 


INDEX 


989 


Brain,  concussion  of,  mild,  353 

severe,  353 

symptoms  of,  352 

treatment  of,  354 
contusion  of.  356 

prognosis  of,  356 

symptoms  of,  356 

treatment  of,  356 
cysts  of,  368 
diseases  of,  359 
endothelioma  of,  368 
fibroma  of,  368 
glioma  of,  368 
inflammation  of,  359 
injuries  of,  352 
lacerations  of,  356 

prognosis  of,  356 

symptoms  of,  356 

treatment  of,  356 
membranes  of,  contusions  of,  356 

inflammation  of,  359 

laceration  of,  356 
neuroma  of,  368 
of  newborn,  injuries  of,  367 
operations  on,  371 
prolapse  of,  366 

treatment  of,  366 
sarcoma  of,  368 
sinuses  of,  thrombosis  of,  363 
exophthalmos  in,  363 
symptoms  of,  363 
treatment  of,  364 
tumors  of,  368 

astereognosis  in,  369 

ataxia  in,  369 

choked  disk  in,  369 

deafness  in,  369 

dysphagia  in,  369 

gait  in,  369 

headache  in,  368,  370 

hemianesthesia  in,  369 

hemianopsia  in,  369 

hemiplegia  in,  369 

Jacksonian  epilepsy  in,  369 

motor  aphasia  in,  369 

nystagmus  in,  369 

optic  neuritis  in,  368 

pain  in,  369 

prognosis  of,  370 

symptoms  of,  368 

syphilis  and,  370 

tinnitus  in,  369 

treatment  of,  370 

tuberculosis  and,  370 

vertigo  in,  368 

vomiting  in,  368,  369 
Branchial  cleft,  carcinoma  of,  395 
cysts,  393 
fistula?,  392 
Breast,  adenocele  of,  490 
binder,  138 
carcinoma  of,  492 

acinous,  492 

diagnosis  of,  496 


Breast,  carcinoma  of,  duct,  495 
encephaloid,  495 
operation  for,  497 

Halstead's,  498 
prognosis  of,  496 
scirrhus,  493 
symptoms  of,  4 '.)."> 
treatment  of,  497 
ar-rays  in,  499 
chondrosarcoma  of,  491 
congenital  absence  of,  483 
cyst-adenoma  of,  488,  490 
cyst osar coma  of,  491 
fibro-adenoma  of,  489,  490 
diagnosis  of,  490 
treatment  of,  41)1 
fibrocyst-adenoma  of,  490 
hypertrophy  of,  diffuse  virginal,  487 
treatment  of,  488 
senile  parenchymatous,  488 
symptoms  of,  489 
intracanalicular   adenopapilloma  of, 
490 
myxoma  of,  490 
malformations  of,  483 
myxosarcoma  of,  491 
Paget's  disease  of,  90,  487 
sarcoma  of,  491 

diagnosis  of,  491 
treatment  of,  492 
syphilis  of,  485 
tuberculosis  of,  486 

treatment  of,  486 
tumors  of,  489 
Brewer's  dressing  for  Colles'  fracture,  848 
empyema  drainage  tube,  468 
tourniquet  in  amputations,  945 
Bronchi,  bacteria  of,  22 
dilatation  of,  471 

symptoms  of,  471 
treatment  of,  471 
Bronchiectasis,  471 
symptoms  of,  471 
treatment  of,  471 
Bronchocele,  399 

Brophy's  operation  for  cleft  palate,  420 
Brown's  wire  suture  in  ehiloplasty,  418 
Bryant's  empyema  drainage  tube,  467 
Bubo,  chancroidal,  689 
Bubonocele,  923 
Buck's  extension  apparatus  in  fractures 

of  femur,  857 
Bulb  and  parachute  snare,  443 
Bulbous  bougie,  684 
Bunions,  302 

treatment  of,  302 
Burns  of  scalp,  330 
of  skin,  189 

treatment  of,  190 
Bursa,  extension  of  infection  from,  221 
Bursa?,  adventitious,  300 
anatomic,  300 
contusions  of,  300 
diseases  of,  300 


990 


INDEX 


Bursa?,  inflammation  of,  300 
injuries  of,  300 
tumors  of,  302 
Bursitis,  acute,  300 
chronic,  300 

treatment  of,  301 
subacromial,  301 

treatment  of,  302 
subdeltoid,  301 

treatment  of,  302 
trade,  302 


Cachexia  strumipriva,  412 
Calcaneus,  fractures  of,  870 

diagnosis  of,  871 
Calcification  of  media  of   bloodvessels, 

248 
Calcium  oxalate  calculi,  657 
Calculi,  ammonium  urate,  657 
calcium  oxalate,  657 
cystine,  658 
phosphate,  657 
prostatic,  7 10 
uric  acid,  657 
xanthine,  658 
Calculus  anuria,  623, 626 

nephrotomy  in,  627 
pain  in,  626 
prognosis  of,  627 
symptoms  of,  626 
treatment  of,  627 
ureterotomy  in,  627 
z-rays  in,  627 
renal,  622 
ureteral,  635 
urethral,  687 
vesical,  657 
Cancer,  87.     See  Carcinoma. 

en  cuirasse,  494 
Cancrum  oris,  57 
Cannula,  Crile's  transfusion,  149 

Konig's  spiral,  451 
Capillary  hemorrhage,  123 
Carbolic  gangrene,  55 
Carbuncle,  198 
of  face,  391 
of  neck,  391 
treatment  of,  199 
Carcinoma,  87 

of  bladder,  665 
of  bone,  765 
of  branchial  cleft,  395 
of  breast,  492 
acinous,  492 
duct,  495 
encephaloid,  495 
scirrhus,  493 
colloid,  89 
cylindrical,  87,  91 
duct,  91 
encephaloid,  91 


Carcinoma  of  gall-bladder,  583 

of  gall-ducts,  584 

of  intestine,  551 

of  kidney, 628 

of  liver,  574 

of  lung,  474 

of  lymph  nodes,  293 

of  mediastinum,  476 

of  pancreas,  593 

of  parotid  gland,  398 

of  prostate  gland,  715 

of  rectum,  731 

scirrhus,  90 

of  skin,  238 

spheroidal,  87, 90 

of  spleen,  599 

squamous,  87, 92 

of  stomach,  530 

of  sublingual  gland,  398 

of  submaxillary  gland,  398 

of  testicle,  705 

of  thyroid  gland,  411 

of  tongue,  435 
Carcinomatous  ulcers  of  skin,  234 
Garden's  method  of  amputation  at  knee- 
joint,  960 
Cardiac  massage  in  wounds  of  heart,  247 

weakness,  120 
Cardiolysis,  244 
Cardiospasm,  529 

symptoms  of,  529 

treatment  of,  529 
Caries  of  bone,  753 
Carotid  artery,  ligation  of,  270 
Carpal  bones,  dislocations  of,  893 
fractures  of,  848 

symptoms  of,  848 
treatment  of,  848 
Carpometacarpal   articulations,   disloca- 
tions of,  894 
Cartilage,  floating,  in  joint,  769 

semilunar,  dislocations  of,  903 
Castration,  716 
Catarrhal  appendicitis,  559 

cholecystitis,  580 
Catheter,  flexible,  148 

Mercier's  coude,  148 

metallic,  148 

prostatic,  148 
Catheterism   in   senile    hypertrophy    of 

prostate  gland,  713 
Catheterization,  147 
Catheter,  Gouley's,  684 
Cauda  equina,  injuries  of,  382 
Cavernous  angioma,  85 
of  spleen,  599 

lymphangioma,  85 
Cellulitis,  195 

of  abdomen,  507 

acute  mediastinal,  475 

causes  of,  195 

in  erysipelas,  41 

gangrenous,  56 

of  neck,  389 


INDEX 


'.)<)! 


Cellulitis  of  penis,  688 
of  scalp,  331 

of  scrotum,  (588 
symptoms  of,  19(5 
treatment  of,  196 
operative,  196 
Cephalagia,  traumatic,  367 
Cerebellum,  lesions  of,  340 
Cerebral  apoplexy,  123 

hemisphere,  cortex  of,  345 
injuries  of  newborn,  367 
palsy,  infantile,  367 
Cerebrospinal  meningitis,  360 
Cervical  lymph  nodes,    tuberculosis  of, 
285 
sympathetic    nerves,    resection    of, 
for       exophthalmic 
goitre,  318 
for  glucoma,  318 
Chain-stitch  suture,  145 
Chancre,  62 

of  penis,  690 
Chancroid,  phagedenic,  689 
Chancroidal  bubo,  689 

ulcers  of  rectum,  728 
Charcot's  disease  of  joints,  801 
Cheek,  epithelioma  of,  434 
Cheever's  lateral  pharyngotomy,  439 
Chemosis  in   thrombosis   of    sinuses   of 

brain,  363 
Chemotaxis  in  acute  inflammation,  32 
Chest  binder,  sling  and,  141 
Chest-wall,  abscess  of,  462 
axillary,  463 
subpectoral,  462 
chrondroma  of,  464 
contusions  of,  459 

treatment  of,  459 
cysts  of,  dermoid,  463 
echinococcus,  463 
sebaceous,  463 
diseases  of,  462 
epithelioma  of,  464 
fibroma  of,  463 

molluscum  of,  463 
injuries  of,  459 
lipoma  of,  463 
osteoma  of,  463 
sarcoma  of,  463,  464 
tumors  of,  463 

prognosis  of,  464 
treatment  of,  464 
wounds  of,  460 

chylothorax  and,  460 
hemothorax  and,  460 
pneumothorax  and,  460 
treatment  of,  461 
Cheyne-Stokes'   respiration   in  acidosis, 
119 
in  compression  of  brain,  355 
in  uremia,  122 
Chiloplasty,  417 

Brown's  wire  suture  in,  418 
Lane's  suture  in,  418 


Chiloplasty,  Mirault's  operation,  418 

Simon's  operation,  418 
Chismore  evacuator,  660 
Chloroform,  administration  of,  164,  165 
after-effects  of,  165 
indications  for,  164 
Choked  disk  in  tumors  of  brain,  369 
Cholangitis,  582 

prognosis  of,  583 

symptoms  of,  582 

treatment  of,  583 
Cholecystectomy,  586 
Cholecystenterostomy,  587 
Cholecystitis,  579 

catarrhal,  580 

chills  in,  581 

fever  in,  581 

gangrenous,  580 

pain  in,  580,  581 

prognosis  of,  581 

suppurative,  580 

symptoms  of,  580 

treatment  of,  582 

vomiting  in,  581 
Cholecystotomy,  585,  586 
Choledochotomy,  586 

transduodenal,  587 
Cholelithiasis,  575 

acute  pancreatitis  in,  578 

complications  of,  578 

fever  in,  578 

jaundice  in,  577 

pain  in,  576 

prognosis  of,  578 

sepsis  in,  578 

skin  in,  578 

symptoms  of,  576 

treatment  of,  579 

urine  in,  578 
Chvostek's  symptom  in  tetany,  413 
Chylangioma,  85 
Chylothorax,  278,  465 

treatment  of,  278 

wounds  of  chest-wall  and,  460 
Chylous  ascites,  278 

treatment  of,  278 

hydrocele,  697 
Chondrodystrophia,  756 
Chondroma,  79 

of  bone,  758 

of  chest-wall,  464 

of  joints,  803 

of  spinal  cord,  383 

of  trachea,  448 
Chondrosarcoma  of  breast,  491 
Chorionepithelioma,  95 
Cigarette  drain,  143 
Circular  enterorrhaphy,  554 

method  of  amputation,  949 
Circulatory  ulcers  of  skin,  230 
Circumcision  in  phimosis  of  penis,  690 
Cirrhosis  of  liver,  ascites  and,  surgical 
treatment  of,  574 

of  spleen,  hypertrophic,  599 


992 


INDEX 


Cirsoid  aneurism,  249 
Clavicle,  dislocations  of,  878 

of  acromial  end  of,  878 

diagnosis  of,  879 
downward,  878 
treatment  of,  879 
upward,  878 
of  sternal  end  of,  878 

diagnosis  of,  878 
treatment  of,  878 
fractures  of,  828 

complications  of,  829 
diagnosis  of,  829 
Moore's  dressing  for,  828 
Sayre's  dressing  for,  830 
treatment  of,  829 
Clavus,  228 

treatment  of,  228 
Cleft  palate,  415 

Brophy's  operation  for,  420 
Lane's  operation  for,  421 
Langenbeck's  operation  for,  421 
operations  for,  420 
staphylorrhaphy  for,  420 
uranoplasty  for,  420 
Club-foot,  973 

congenital,  973 
treatment  of,  975 
Club-hand,  980 

Cocaine  in  local  anesthesia,  168,  170 
Coin-catcher,  442 
Colic,  appendicular,  559 
Colles'  fracture,  843 

Brewer's  dressing  for,  848 
complications  of,  846 
diagnosis  of,  844 
prognosis  of,  846 
treatment  of,  846 
law  in  congenital  syphilis,  66 
Colloid  carcinoma,  89 

of  stomach,  531 
goitre,  400 
Colon  bacillus,  acute  osteomyelitis  and, 
741 
dilatation  of,  congenital  idiopathic, 
569 
prognosis  of,  570 
symptoms  of,  569 
treatment  of,  570 
Colonic  absorption  of   ether,  anesthesia 

by,  167 
Colostomy,  558 
Comminuted  fractures,  806 
Common  carotid  artery,  ligation  of,  270 
femoral  artery,  ligation  of,  275 
iliac  artery,  ligation  of,  274 
Composite  odontome,  436 
Compound  fractures,  806 
Compression  of  brain,  354 

of  nerve  trunks,  306 
Concussion  of  brain,  352 

of  spinal  cord,  380 
Condyles  of  femur,  fractures  of,  862 
of  humerus,  fracture  of,  838 


Congenital  absence  of  breast,  483 
of  urethra,  672 

anomalies  of  spleen,  596 

club-foot,  973 

cysts,  99 

dislocations,  873 
of  hip,  966 

hydrocele,  697 

idiopathic  dilatation  of  colon,  569 

inguinal  hernia,  922 

malformations  of  anus,  723 
of  bladder,  646 
of  rectum,  723 

rickets,  756 

spastic  paralysis,  367 

stricture  of  rectum,  723 

syphilis,  66 

umbilical  fistula;,  507 
hernia,  934 
Connective  tissue  tumors,  77 
Cornell's  anesthetometer,  163 
Continued  suture,  145 
Contusions  of  abdomen,  500 

of  bladder,  647 

of  brain,  356 

of  bursa?,  300 

of  chest-wall,  459 

of  face,  387 

of  joints,  766 

of  kidney,  603 

of  membranes  of  brain,  356 

of  muscles,  294 

of  neck,  387 

of  nerves,  303 

of  penis,  688 

of  scalp,  326 

of  scrotum,  688 

of  skin,  192 

of  spinal  cord,  380 

of  testicle,  700 

of  urethra,  674 
Coracoid  process  of  scapula,  fracture  of, 

090 

Corn,  228 

treatment  of,  228 
Coronoid  process,  fractures  of,  841 
symptoms  of,  841 
treatment  of,  841 
Corpora  quadrigemina,  lesions  of,  348 
Corpus  callosum,  lesions  of,  348 
Costal  cartilages,  fractures  of,  824 
diagnosis  of,  824 
prognosis  of,  824 
treatment  of,  824 
Cowper's  gland,  cysts  of,  687 
Coxa  valga,  969 
vara,  968 

symptoms  of,  969 
treatment  of,  969 
Cranial  bones,  syphilis  of,  343 
pathology  of,  344 
symptoms  of,  344 
treatment  of,  344 
tuberculosis  of,  343 


INDEX 


<M1 


Cranial  bones,  tuberculosis  of,  pathology 
of,  343 
symptoms  of,  343 
treatment  of,  343 
topography,  349 

auditory  area,  352 
higher  psychical  area,  350 

visual  area,  352 
lower  cortical  visual  area,  352 
motor  area,  351 
speech  area,  351 
stereognostic  area,  351 
Craniotabes,  68 
Craniotomy,  371 

osteoplastic,  372 
Cretinism,  412 

Crile's  transfusion  cannula,  149 
Crura  cerebri,  lesions  of,  340 
Cryoscopy  in  examination  of  urine,  638 
Curette,  Gottstein's,  430 
Curtis'  adenoid  forceps,  429 
Gushing' s    purse-string    operations    for 

femoral  hernia,  933 
Cylindrical  carcinoma,  87,  91 
Cyst-adenoma  of  breast,  488,  490 

of  pancreas,  594 
Cystic  degeneration  of  pancreas,  595 
Cystine  calculi,  658 
Cystitis,  650 

diagnosis  of,  651 
pain  in,  651 
symptoms  of,  651 
treatment  of,  652 
in  tumors  of  bladder,  666 
urine  in,  651 
in  vesical  calculus,  658 
Cystosarcoma  of  breast,  491 
Cystoscopy  in   tuberculosis  of   bladder, 
656 
in  ureteral  calculus,  635 
Cysts,  96 

of  abdominal  wall,  507 
of  adrenal  gland,  629 
of  bone,  760 
of  brain,  368 
branchial,  393 
congenital,  99 
of  Cowper's  gland,  687 
daughter,  98 
degeneration,  97 
dental,  436 
dermoid,  99 

of  chest-wall,  463 
of  kidney,  629 
of  mediastinum,  476 
ovarian,  99 
of  scalp,  334 
of  scrotum,  692 
of  skin,  235 
echinococcus,  of  chest-wall,  463 
of  kidney,  629 
of  lung,  475 
of  mediastinum,  476 
of  spleen,  599 
63 


Cysts,  extravasation,  97 
exudation,  97 
formed  by  distension  of  preexisting 

cavities,  96 
from  persistent  fetal  structures,  100 
granddaughter,  98 
hemorrhagic,  of  pancreas,  594 
hydatid,  98 

of  liver,  573 

of  pancreas,  594 
implantation,  98 
of  intestine,  550 
of  kidney,  629 
of  mouth,  434 
mucous,  97 
of  new  formation,  97 
of  pancreas,  594 
parasitic,  98 
retention,  97 

of  pancreas,  594 
sebaceous,  97 

of  chest-wall,  463 

of  scalp,  333 

of  scrotum,  692 

of  skin,  235 
serous,  97 
of  spleen,  599 
thyroglossal,  393 
of  ureter,  637 
of  urethra,  687 


Dactylitis,  syphilitic,  750 

tuberculous,  751 
Dalrymple's  sign  in  exophthalmic  goitre, 

406 
Deafness  in  tumors  of  brain,  369 
Decapsulation  in  surgical   treatment  of 

nephritis,  630 
Deciduoma,  95 
Decortication  of  lung,  481 
Deformities  of  ear,  457 
Degeneration  of  bone,  756 
cystic,  of  pancreas,  595 
cysts,  97 

fatty,  of  bloodvessels,  248 
Delirium  tremens,  115 

prophylaxis  in,  116 

symptoms  of,  115 

treatment  of,  115 
Dental  cysts,  436 
Dermatitis,  x-ray,  193 
Dermoid  cysts,  99 

of  abdominal  wall,  507 

of  chest-wall,  463 

of  face,  392 

of  kidney,  627,  629 

of  mediastinum,  476 

of  neck,  392 

ovarian,  99 

postrectal,  730 

of  scalp,  334 


994 


INDEX 


Dermoid  cysts  of  scrotum,  G92 
of  skin,  235 

atheromatous,  235 
traumatic,  98 
Desmoids,  297 

of  abdominal  wall,  508 
Diabetic  gangrene,  57 
Diaphragmatic  hernia,  940 
Dietls'  crisis  in  movable  kidney,  607 
Diffuse  prostatitis,  708 
Dilatation  of  bronchi,  471 

of  colon,  congenital  idiopathic,  569 
of  stomach,  519 
Diplococcus  in  acute  arthritis,  774 
Disarticulation  of  tarsometatarsal  joint, 

963 
Dislocations,  873 
of  ankle,  905 
of  astragalus,  907 
of  bones  of  hand,  894 
of  carpal  bones,  893 
of     carpometacarpal     articulations, 

894 
causation  of,  873 
of  clavicle,  878 

acromial  end,  878 
sternal  end,  878 
complete,  873 
complicated,  873 
compound,  873 

treatment  of,  876 
congenital,  873 
diagnosis  of,  874 
double,  873 
of  elbow,  889 
of  fibula,  905 
of  hip,  896 

congenital,  966 
incomplete,  873 
of  inferior  radio-ulnar  articulation, 

892 
of  jaw,  876 

bilateral,  877 
of  joints,  770 
of  knee,  901 

of  mediocarpal  articulation,  893 
mediotarsal,  907 
of  metatarsal  bones,  907 
multiple,  873 
old,  treatment  of,  875 
of  patella,  900 
pathologic,  873 

anatomy  of,  874 
of  phalanges  of  foot,  9Q8 

of  hand,  895,  896 
of  radiocarpal  articulation,  893 
of  radius,  890 
of  ribs,  883 

of  semilunar  bones,  893 
cartilage,  770,  903 
of  shoulder,  883 
simple,  873 
of  spine,  879 

bilateral,  880 


Dislocations  of  spine,  unilateral,  880 
spontaneous,  873 
of  sternum,  882 

body  from  manubrium,  882 
ensif  orm  process,  882 
subastragaloid,  906 
symmetric,  873 
of  tarsal  bones,  907 
of  tendons,  296 
tibiotarsal,  905 
traumatic,  873 
treatment  of,  875 
of  ulna,  890 
of  wrist,  892 
Dissecting  aneurism,  249 
Diverticula  of  bladder,  647 
of  esophagus,  445 
of  intestine,  546 
Diverticulitis,  acute,  548 
of  sigmoid,  548 

symptoms  of,  549 
treatment  of,  549 
treatment  of,  548 
chronic,  of  sigmoid,  549 
Dorsalis  pedis  artery,  ligation  of,  277 
Drainage  tube,  empyema,  Brewer's,  468 
Bryant's,  467 
Wilson's,  466 
rubber,  143 
Dressings,  wet,  144 

for  wounds,  143 
Duct  carcinoma,  91 

of  breast,  495 
papilloma,  87 
Duodenal  ulcer,  520, 525 

in  burns  of  skin,  190 
hemorrhage  in,  526 
perforation  in,  526 
prognosis  of,  526 
stenosis  in,  526 
symptoms  of,  525 
treatment  of,  526 
Dupuytren's  contraction,  299 
symptoms  of,  299 
treatment  of,  299 
splint  in  Pott's  fracture,  869 
Dura  mater,  anatomy  of,  335 

inflammation  of,  359 
Dysenteric  ulcers  of  intestine,  545 
Dyspepsia,  appendicular,  566 


Ear,  deformities  of,  457 
diseases  of,  457 
furuncles  of,  457 
hematoma  of,  457 
inflammation  of,  457 
Ecchymosis,  definition  of,  123 
Echinococcus  cysts  of  chest-wall,  463 
of  kidney,  629 
of  lung,  475 
of  mediastinum,  476 


INDEX 


995 


Echinococcua  cysts  of  spleen,  599 
Ectopic  liver,  570 
spleen,  596 
testicle,  699 
Edebohls'  incision  for  exposure  of  kid- 
ney, 639 
Edema  of  glottis,  440 
malignant,  48 
bacillus  of,  48 
prognosis  of,  49 
of  scalp,  331 
Elbow,  dislocations  of,  889 
backward,  889 
complications  of,  891 
diagnosis  of,  890 
external,  890 
forward,  889 
internal,  890  - 
lateral,  890 
mixed,  890 
treatment  of,  891 
tuberculosis  of,  800 
excision  in,  800 
symptoms  of,  800 
treatment  of,  800 
Elbow-joint,  amputation  at,  954 
traumatic  arthritis  in,  772 
tuberculous  arthritis  of,  800 
Electric  urethroscope,  679 
Elephantiasis,  282 

Filaria  sanguinis  hominis  and,  282 
skin  in,  283 
symptoms  of,  283 
treatment  of,  283 
Embolism,  gangrene  and,  55 

postoperative  pulmonary,  treatment 
of,  187 
Emphysema,  pulmonary,  473 
Emphysematous       gangrene,      Bacillus 
aerogenes  capsulatus  infections  and,  51 
Empyema,  465 

of  appendix,  562 
drainage  tubes  in,  466,  467,  468 
Fowler's  operation  for,  481 
of  maxillary  antrum,  426 
resection  of  ribs  for,  479 
symptoms  of,  466 
treatment  of,  466 
Encephalitis,  361 

symptoms  of,  361 
treatment  of,  361 
Encephalocele,  365 

treatment  of,  366 
Encephaloid  carcinoma,  91 

of  breast,  495 
Endarteritis,  syphilitic,  65 
Endo-aneurysmorrhaphy,  258 
Endothelioma,  84 
of  brain,  368 
of  penis,  693 
of  pleura,  474 
of  spinal  cord,  383 
of  spleen,  599 
Ensiform  process,  dislocations  of,  882 


Enterectomy,  553 
Enterocele,  913 
Entero-epiplocele,  913 
Enteroliths  in  stomach,  518 
Enterorrhaphy  circular,  554 

Maunsel's  method  of,  556 
Enterotomy,  553 
Enucleation  in  simple  goitre,  404 
of  tonsils,  430 

Mathew's  operation  for,  430 
Epididymectomy,  716 
Epididymis,  inflammation  of,  700 
operation  on,  716 
syphilis  of,  702 

diagnosis  of,  703 
treatment  of,  703 
Wassermann  reaction  in,  703 
Epididymitis,  acute,  700 

symptoms  of,  701 
pain  in,  701 
treatment  of,  701 
syphilitic,  702 
Epididy  mo  vasotomy,  716 
Epilepsy,  focal,  366 
Jacksonian,  367 
traumatic,  366 

prognosis  of,  367 
treatment  of,  367 
Epiphyseal     separation    in    fracture    of 
femur,  862 
of  humerus,  831,  838 
Epiphysitis,  acute,  748 
Epiplocele,  913 
Epispadias,  673 
Epistaxis,  425 

in  acute  spontaneous  osteomyelitis, 

341 
definition  of,  123 
treatment  of,  425 
Epithelial  nests,  93 
pearls,  93 
tissue  tumors,  77 
Epithelioma,  87,  92 

of  abdominal  wall,  507 

basal-celled,  93 

of  bladder,  665 

of  cheeks,  434 

of  chest-wall,  464 

of  face,  396 

of  gums,  434 

of  larynx,  446 

of  lip,  397 

of  mouth,  434 

of  nose,  431 

of  palate,  434 

of  parotid  gland,  398 

of  penis,  692 

of  pharynx,  448 

of  rectum,  731 

of  scrotum,  693 

of  skin,  238 

of  sublingual  gland,  398 

of  submaxillary  gland,  398 

of  testicle,  705 


996 


INDEX 


Epithelioma  of  tongue,  434 
of  tonsil,  434 
of  ureter,  637 
of  urethra,  687 
Epitheliomatous  ulcers  of  skin,  233 
Epitheloid  cells,  59 
Eponychia,  202 

treatment  of,  204 
Eponychium,  199 
Epulis,  80,  435 
Erb's  test  in  tetany,  413 
Ergot  gangrene,  55 
Erysipelas,  40 

acute  septic  leptomeningitis  and,  360 
cellulitis  in,  41 
endocarditis  in,  41 
etiology  of,  40 
of  face,  388 
fever  in,  41 
leukocytosis  in,  41 
meningitis  in,  41 
morbid  anatomy  of,  40 
of  neck,  389 
neonatorum,  40 
nephritis  in,  41 
phlegmonous,  41 
pneumonia  in,  41 
prognosis  of,  4l 
of  scalp,  332 
septicemia  in,  41 
of  skin,  193 
streptococcus  and,  40 
symptoms  of,  41 
treatment  of,  41 
Erysipeloid,  42 

infections  of  hand,  228 
Esmarch  inhaler,  158 
Esophagotomy,  external,  456 
Esophagus,  carcinoma  of,  448 
diseases  of,  440 
diverticula  of,  445 

symptoms  of,  445 
treatment  of,  446 
foreign  bodies  in,  441 

symptoms  of,  441 
treatment  of,  441 
operations  on,  449 
stricture  of,  444 

diagnosis  of,  444 
treatment  of,  444 
tumors  of,  448 

diagnosis  of,  448 
treatment  of,  448 
Estlander's  thoracoplasty,  479 
Ether,  administration  of,  156,  158 
caution  in,  158 
closed  method,  159 
cone  method,  161 
open  method,  158 
colonic  absorption  of,  anesthesia bv, 
167 
Eucaine  in  local  anesthesia,  171 
Evacuator,  Chismore,  (560 
Excision  in  exophthalmic  goitre,  409 


Excision  in  simple  goitre,  403 
in  tuberculosis  of  elbow,  800 
of  hip,  795 
of  knee,  798 
of  shoulder,  799 

Excoriation  of  skin,  229 

Exenteration  in  simple  goitre,  404 

Exophthalmic  goitre,  404 

Exostoses  of  spinal  cord,  383 

Exposure  of  kidney,  639 

Exstrophy  of  bladder,  646 

Extensor  tendon,  202 

External  carotid  artery,  ligation  of,  271 
iliac  artery,  ligation  of,  275 

Extirpation  in  exophthalmic  goitre,  409 
in  simple  goitre,  403 

Extradural  hemorrhage,  356,  380 

Extraperitoneal  injuries  of  abdomen,  500 

Extravasation  cysts,  97 

Exuberant  ulcers  of  skin,  230 

Exudation  cysts,  97 


Face,  actinomycosis  of,  69 

anthrax  of,  391 

Bacillus  anthracis  in,  391 
treatment  of,  391 

bones  of,  fractures  of,  820 

carbuncle  of,  391 

treatment  of,  391 

contusions  of,  387 

dermoids  of,  392 

diseases  of,  388 . 

epithelioma  of,  396 
treatment  of,  397 

erysipelas  of,  388 

symptoms  of,  389 
treatment  of,  389 

inflammation  of,  388 

injuries  of,  387 

lipoma  of,  396 

tumors  of,  392 

wounds  of,  387 
Facial  artery,  ligation  of,  271 

nerves,  paralysis  of,  318 

operations  for,  318 
False  aneurism,  123 
Farcy,  49.     See  also  Glanders. 

acute,  49 

buds,  49 

chronic,  50 
Fascia;,  diseases  of,  299 

injuries  of,  294 

tuberculosis  of,  299 
Fascial  space,  infection  of,  215 
Fat-embolism,  109 

convulsions  in,  110 

delirium  in,  110 

dyspnea  in,  1 10 

fever  in,  111 

fractures  and,  811 

hematuria  in,  110 


INDEX 


997 


Fat-embolism,  pain  in,  110 

sputum  in,  1 10 
symptoms  of,  110 

treat  nii'iit  of,  111 
urine  in,  1 1 1 
.  Fecal  tistula,  appendicitis  and,  569 
Femoral     adenitis,     diagnosis    of,     from 
femoral  hernia,  932 
artery,  ligation  of,  275 
hernia,  (»M1 
femur,  fractures  of,  852 
compound,  862 
of  condyles  of,  862 
symptoms  of,  862 
treatment  of,  862 
of  head  of,  852 
intercondyloid,  863 
prognosis  6f,  863 
symptoms  of,  863 
treatment  of,  863 
of  lower  extremity  of,  862 
of  neck  of,  852 

separation  of  epiphyses  in,  862 
symptoms  of,  862 
treatment  of,  862 
of  shaft  of,  859 

diagnosis  of,  859 

prognosis  of,  861 

treatment  of,  861 

treatment  of,  operative,  863 

of  trochanters  of,  852 

of  upper  extremity  of,  852 

Buck's   extension   ap- 
paratus in,  857 
diagnosis  of,  853 
Hodgen's      suspended 

splint  in,  858 
prognosis  of,  854 
treatment  of,  855 
Whitman's  method  of 
reduction  of,  855 
Fibro-adenoma  of  breast,  489,  490 
Fibrocyst-adenoma  of  breast,  490 
Fibrocystic  diseases,  705 
Fibroma,  77 

of  bone,  760 

of  brain,  368 

of  chest-wall,  463 

durum,  77 

of  intestine,  550 

of  kidney,  627 

of  larynx,  446 

of  mediastinum,  476 

molle,  77 

molluscum  of  chest-wall,  463 

of  skin,  237 
of  muscles,  297 
of  nerves,  315 
of  rectum,  730 
of  skin,  237 
of  spinal  cord,  383 
of  spleen,  599 
of  trachea,  448 
Fibromyxoma  of  bladder,  665 


Fibroneuroma  of  abdominal  wall,  507 
of  nerves,  315 

of  skin,  237 
Fibrous  odontome,  436 

polypus,  428 
stricture  of  rectum,  726 
Fibula,  dislocations  of,  905 

fractures  of,  867 
Figure-of-eight  bandage,  134 
Filaria  medinensis  in  guinea-worm  dis- 
ease of  skin,  228 
sanguinis  hominis,   hematuria  and, 
654 
in    obstruction    of    lymph 
channels,  282 
Finger-end  infections,  202 
Fingers,  amputations  of,  952 

base  of,  subcutaneous  abscesses  at, 

212 
supernumerary,  981 
web  of,  subcutaneous  abscess  at,  212 
webbed,  980 
Finney's  operation  for  pyloroplasty,  535 
Fissures  of  anus,  729 
Fistula  in  ano,  725 

diagnosis  of,  725 
treatment  of,  726 
branchial,  392 
congenital  umbilical,  507 

treatment  of,  507 
definition  of,  37 
fecal,  appendicitis  and,  569 
thyroglossal,  393 
Flat-foot,  976 

diagnosis  of,  977 
symptoms  of,  976 
treatment  of,  977 
Whitman's  brace  for,  978 
Flexible  catheter,  148 
Floating  cartilage  in  joint,  769 
Focal  epilepsy,  366 
Follicular  odontome,  436 

prostatitis,  708 
Foot,  bones  of,  fracture  of,  870 
diagnosis  of,  871 
treatment  of,  871 
perforating  ulcer  of,  317 

treatment  of,  318 
phalanges  of,  dislocations  of,  908 
diagnosis  of,  908 
treatment  of,  908 
fractures  of,  871 
weak,  976 
Forearm,  fractures  of,  840 
Foreign  bodies  in  bladder,  650 
in  esophagus,  441 
in  heart,  244 
in  larynx,  440 
in  nose,  425 
in  pericardium,  241 
in  stomach,  518 
in  trachea,  440 
in  urethra,  687 
Fowler's  operation  for  empyema,  481 


998 


INDEX 


Fracture-box,  814 
Fracture-dislocation,  873 

of  spine,  880 
Fractures,  806 

of  astragalus,  870 
of  atlas  of  spine,  378 
of  axis  of  spine,  378 
of  body  of  scapula,  827 
of  bones  of  face,  820 

of  foot,  870 

of  lower  extremity,  852 

of  trunk,  823 

of  upper  extremity,  826 
of  both  bones  of  leg,  866 
of  calcaneus,  870 
of  carpal  bones,  850 
of  clavicle,  828 
Colles',  843 
comminuted,  806 
complications  of,  810 

late,  812 
compound,  806,  810 

treatment  of,  817 
of  coronoid  process,  841 
of  costal  cartilages,  824 
delayed  union  in,  812 
delirium  tremens  and,  811 
diagnosis  of,  808 

x-rays  in,  809 
double,  806 
etiology  of,  806 
fat-embolism  and,  811 
of  femur,  852 

compound,  862 

condyles,  862 

head,  852 

intercondyloid,  863 

lower  extremity,  862 

neck,  852 

separation  of  epiphyses  in,  862 

shaft,  859 

trochanters,  852 

upper  extremity,  852 
of  fibula,  867 
of  forearm,  840 
gangrene  and,  812 
green-stick,  806 
hematoma  and,  812 
of  humerus,  831 

anatomical  neck  of,  831 

epiphyseal  separation  in,   831, 
838 

external  condyle  of,  838 

lower  extremity  of,  835 

shaft  of,  834 

surgical  neck  of,  831 

tuberosities  of,  831 

upper  extremity  of,  831 
impacted,  806 
incomplete,  806 
ischemic  paralysis  and,  810 
prognosis  of,  811 
symptoms  of,  811 
treatment  of,  811 


Fractures  of  joints,  770 
longitudinal,  806 
of  lower  jaw,  822 
of  malar  bone,  821 
of  metatarsal  bones,  871 
multiple,  806 

muscular  weakness  and,  812 
of  nasal  bones,  820 
non-union  in,  812 
old,  806 

of  olecranon,  840 
paralysis  and,  812 
of  patella,  864 
of  pelvis,  825 
of  phalanges  of  foot,  871 

of  hand,  851 
plaster  dressings  in,  815 
Pott's,  867 

pseudarthrosis  and,  812 
punch,  850 
of  radius,  shaft,  842 

upper  extremity,  841 
recent,  806 
reduction  of,  812 
repair  of,  807 
of  ribs,  824 
Roberts',  844 
of  scapula,  826 

acromion  process  of,  826 

body  of,  827 

coracoid  process  of,  828 

glenoid  process  of,  827 
of  scapula,  neck  of,  827 

spine  of,  827 
simple,  806 

treatment  of,  812 
single,  806 
of  skull,  336 
of  spine,  374 
spiral,  806 
splints  for,  813 
of  superior  maxilla,  822 
of  tibia,  866 
transverse,  806 
traumatic  aneurisms  and,  812 
treatment  of,  general,  812 

open,  816 
T-shaped,  806 
united,  806 
ununited,  806 
of  upper  jaw,  822 
in  vicinity  of  wrist-joint,  843 
vicious  union  in,  812 
Volkmann's  contracture  in,  810 
V-shaped,  806 
of  zygoma,  821 
Frambesia  of  skin,  228 
Friedrich's  thoracoplasty,  480 
Frontal  sinus,  inflammation  of,  427 
symptoms  of,  427 
treatment  of,  427 
Frost-bite,  gangrene  from,  55 
Fungating  ulcers  of  skin,  230 
Furuncle  of  skin,  194 


INDEX 


999 


Fui  uncle  of  skin,  symptoms  of,  194 

treatment  of,  194 
Furunculosis  of  scalp,  331 
Fusiform  aneurism,  249 


G 


Galactocele,  485 

treatment  of,  485 
Gall-bladder,  carcinoma  of,  583 
prognosis  of,  584 
symptoms  of,  583 
treatment  of,  585 

operations  on,  585 

tumors  of,  583 
Gall-ducts,  carcinoma  of,  584 
jaundice  in,  584 
prognosis  of,  o85 
symptoms  of,  5S4 
treatment  of,  585 

operations  on,  585 

tumors  of,  584 
Gall-stones,  575 
Ganglia,  298 

compound  palmar,  299 

treatment  of,  298 
Gangrene,  51 

of  bone,  753 

carbolic,  55 

clinical  types  of,  53 

diabetic,  57 

dry,  52 

embolism  and,  55 

emphysematous,  Bacillus  aerogenes 
capsulatus  infections  and,  51 

ergot,  55 

etiology  of,  51 

fever  in,  52 

fractures  and,  812 

from  frost-bites,  55 

inflammation,  56 

ischemic,  55 

ligature  and,  55 

line  of  demarcation  in,  52 

of  lung,  472 

moist.  52 

presenile,  54 

in  Raynaud's  disease,  55 

senile,  53 

in  strangulated  hernia,  918 

symptoms  of,  52 

thrombosis  and,  55 

traumatic,  55 

treatment  of,  53 
Gangrenous  appendicitis,  560 

cellulitis,  56 

cholecystitis.  580 

pancreatitis,  589 

stomatitis,  431 
Gas  bacillus,  50 

pains    following    operations,    treat- 
ment of,  179 
Gasserian  ganglion,  removal  of,  311 


Gastrectomy,  538 

partial,  535 
Gastric  dilatation,  519 

diagnosis  of,  520 
symptoms  of,  520 
treatment  of,  520 
tuberculosis,  546 
ulcer,  520.  521 

complications  of,  523 
edema  in,  523 
etiology  of,  521 
hemorrhage  in,  523 
hvperchlorhydria  in,  522 
pain  in,  522 
perforation  in,  523 
prognosis  of,  523 
symptoms  of,  522 
treatment  of,  524 
vomiting  in.  522 
Gastroenterostomy,  539 

in  hour-glass  stomach,  530 
Gastrogastrostomv  in  hour-glass  stomach, 

530 
Gastro-intestinal    tract,   tuberculosis  of, 

546 
Gastromesenteric  ileus,  519 
Gastroplasty  in  hour-glass  stomach,  530 
Gastroptosis.  527 
Gastrostomy,  539 
Gastrotomy,  534 
Genital  organs,  operations  on,  716 

tract,  removal  of  entire,  717 
Genito-urinary  tract,  bacteria  of,  23 
Giant-celled  sarcoma,  S4 
Glanders,  49 
acute,  49 
bacillus  of,  49 
chronic,  49 
diagnosis  of,  50 
etiology  of,  49 
morbid  anatomy  of,  49 
pneumonia  in,  49 
symptoms  of,  49 
treatment  of,  50 
Glandular  hj-pospadias,  672 
Glaucoma,  resection  of  cervical  sympa- 
thetic nerves  for,  318 
Gleet,  679 
Glenoid  ligament,  202 

process  of  scapula,  fracture  of,  827 
Glioma,  84 

of  brain,  368 
of  spinal  cord,  383 
Gliosarcoma,  82 
Glossitis,  432 

chronic  superficial,  432 
symptoms  of,  432 
treatment  of,  432 
Glottis,  edema  of,  440 
Gluteal  arterv,  ligation  of,  275 
Goitre,  399 

adenomatous,  400,  401 
asymmetrical,  400 
colloid,  400 


1000 


INDEX 


( loitre,  diffuse  parenchymatous,  400 
exophthalmic,  404 

Dalrymple's  sign  in,  400 

enucleation  in,  410 

etiology  of,  404 

excision  in,  409 

exophthalmos  in,  405 

extirpation  in,  409 

Kocher's  sign  in,  400 

ligation  of  thyroid  arteries  in, 

410 
Moebius'  sign  in,  406 
operations  for,  406 

anesthesia  in,  408 

anoci-association  in,  408 

choice  of,  408 

results  of,  functional     end, 
409 
postoperative,  408 

technic  of,  409 
palpitation  in,  406 
pathology  of,  405 
resection  in,  410 

of    cervical    sympathetic 
nerves  for,  318 
Stellwag's  sign  in,  406 
sympathectomy  in,  407 
symptoms  of,  405 
tachycardia  in,  406 
thymectomy  in,  407 
thymus  in,  405 
thyroid  gland  in,  405 
thyroidectomy  in,  407 
treatment  of,  406 
von  Graef's  sign  in,  406 
intrathoracic,  411 
lingual,  410 

operation  for,  410 
nodular,  400 
simple,  399 

course  of,  403 
cyanosis  in,  402 
dyspnea  in,  402 
edema  in,  402 
enucleation  in,  404 
etiology  of,  400 
excision  in,  403 
exenteration  in,  404 
extirpation  in,  403 
heart  in,  402 
incision  in,  404 
isthmectomy  in,  404 
operations  for,  403 
paralysis  in,  402 
prognosis  of,  403 
resection  in,  404 
stridor  in,  402 
symptoms  of,  401 
thyroid  gland  in,  400 
tracheotomy  in,  404 
treatment  of,  403 
Gonococcus  in  infective  arthritis,  774 
Gottstein's  curette,  430 
Gouley's  catheter,  684 


Gouley's  tunnelled  sound,  684 
Gouty  arthritis,  776 
Granny  knot,  144,  145 
Granulomata,  infective,  34,  35 
Gravel,  622 
Graves'  disease,  404 
Green-stick  fractures,  806 
Gritti's  method  of  amputation  at  knee- 
joint,  960 
Gumma  of  liver,  574 
Gummatous  infiltration  of  lung,  474 

of  palate,  436 

of  pharynx,  436 

of  tongue,  436 
Gums,  epithelioma  of,  434 

sarcoma  of,  435 
Gunning's  interdental  splint  in   fracture 
of  lower  jaw,  823 


H 


Hairballs  in  stomach,  518 
Hallux  vulgus,  979 

treatment  of,  979 
Halsted's    operation    for    carcinoma   of 
breast,  498 
for  inguinal  hernia,  927,  928 
Hammer-toe,  980 

Hand,  bones  of,  dislocations  of,  894 
erysipeloid  infections  of,  228 
fascial  space  of,  infection  of,  215 

diagnosis  of,  222 
hypothenar  eminence  of,  abscess  of, 

'220 
infections  of,  199 
palm  of,  abscess  of,  212 

treatment  of,  215 
phalanges  of,    dislocations   of,    895, 
896 
Levis  extension  apparatus 
in,  896 
fractures  of,  851 
tendon  sheaths  of,  infection  of,  215 
thenar  eminence  of,  abscess  of,  220 
Handkerchief  bandage,  139 
Hare-lip,  415 

bilateral,  Brown's  operation  for,  419 
chiloplasty  for,  417 
complete,  operation  for,  419 
double,  415 
operations  for,  417 
single,  415 
Head  of  femur,  fractures  of,  852 
Heart,  foreign  bodies  in,  244 
diagnosis  of,  244 
treatment  of,  244 
injuries  of,  244 
myoma,  121 
in  simple  goitre,  402 
surgery  of,  experimental,  247 
tamponade,  245 
wounds  of,  245 

cardiac  massage  in,  247 


INDEX 


1001 


Heart,  wounds  of,  diagnosis  of,  245 
hemopericardium  in,  245 
hemorrhage  in,  245 
hemothorax  in,  245 
operations  on,  246 
shock  in,  245 
symptoms  of,  245 
treatment  of,  245 
Heat-prostration,  122 
symptoms  of,  122 
treatment  of,  122 
Hemangioma,  84 
Hemarthrosis,  803 

treatment  of,  803 
Hematemesis,  definition  of,  123 
Hematogenous  infections  of  kidney,  609 
Hematoma  in  contusions  of  scalp,  326 
of  ear,  457 
fractures  and,  812 
Hematomata,  123 
Hematomyelia,  380 
prognosis  of,  381 
symptoms  of,  380 
treatment  of,  381 
Hematonephrosis,  633 
Hematuria,  123,  653 

Bilharzia  hematobia  and,  654 

Filaria  sanguinis  hominis  and,  654 

in  renal  calculus,  623 

in  subperietal  injuries  of  kidney,  603 

treatment  of,  655 

in  tumors  of  bladder,  665 

of  kidney,  628 
in  vesical  calculus,  658 
Hemianesthesia  in  tumors  of  brain,  369 
Hemianopsia  in  tumors  of  brain,  369 
Hemiplegia  in  tumors  of  brain,  369 
Hemolytic  icterus,  598 
Hemopericardium  in  wounds  of  heart, 

245 
Hemophilia,  123 
Hemoptysis,  123 
Hemorrhage,  122 

actual  cautery  in,  125 
acupressure  in,  126 
arterial,  123 
capillary,  123 

in  carcinoma  of  stomach,  532 
digital  pressure  in,  125 
in  duodenal  ulcer,  526 
dyspnea  in,  123 
elevation  of  limb  in,  125 
external,  122 
extradural,  356,  380 
diagnosis  of,  357 
pathology  of,  356 
symptoms  of,  357 
treatment  of,  357 
in  gastric  ulcer,  523 
in  heart,  245 
hot  water  in,  125 
ice  in,  125 
intermediate,  122 
internal,  122 


Hemorrhage,  intracerebral,  358 
intracranial,  356 

intramedullary,  380 

ligature  in,  126 

mechanical  compression  in,  125 

nausea  in,  123 

pial,  358 

postoperative,  175 

delayed,  175 

primary,  175 
primary,  122 
pulse  in,  123 
recurrent,  122 

treatment  of,  127 
respiration  in,  123 
secondary,  122 

treatment  of,  127 
spinal,  380 
styptics  in,  125 
subcutaneous,  122 
subdural,  358,  380 

symptoms  of,  358 

treatment  of,  358 
subpial,  358 
symptoms  of,  123 
torsion  in,  126 
traumatic,  122 
treatment  of,  124 
in  varicose  veins,  264 
venous,  123 
Hemorrhagic  cysts  of  pancreas,  594 

pancreatitis,  589 
Hemorrhoids,  735.     See  also  Piles, 
diagnosis  of,  736 
operation  for,  737 
removal  of,  737 
symptoms  of,  735 
treatment  of,  736 

radical,  736 
Whitehead's  operation  for,  738 
Hemostasis  in  amputations,  945 
Hemothorax  in  wounds  of  chest-wall,  460 

of  heart,  245 
Hernia,  909 

age  and,  912 
anatomy  of,  910 
atrophy  and,  913 
bloodvessels  and,  911 
cerebri,  366 

treatment  of,  366 
classification  of,  913 
diaphragmatic,  940 
embryology  of,  909 
etiology  of,  912 

exciting,  913 
femoral,  931 

diagnosis  of,  932 

from  femoral  adenitis,  932 
from  psoas  abscess,  932 
from  saphenous  varix,  932 

operations  for,  932 
Blake's,  933 
Cushing's  purse-string,  933 

treatment  of,  932 


1002 


INDEX 


Hernia,  heredity  and,  912 
incarcerated,  914 
inflamed,  917 

treatment  of,  917 
inguinal,  921 

acquired,  922 

congenital,  922 

direct,  927 

treatment  of,  928 

indirect,  921 

complete,  923 
diagnosis  of,  923 
incomplete,  923 
treatment  of,  923 

infantile,  922 

oblique,  921 

operations  for,  924 
Bassini's,  925 
Blake's,  928 
Bloodgood's,  927,  929 
Halsted's,  927,  928 
interstitial,  929 
irreducible,  913 

symptoms  of,  916 

treatment  of,  917 
of  large  intestine,  940 
in  linea  semilunaris,  939 

transversa),  939 
Littre's,  919 
lumbar,  940 

morbid  anatomy  of,  914 
of  muscles,  295 
nerves  in,  910 
obstructed,  914 

symptoms  of,  917 

treatment  of,  917 
obturator,  940 

artery  and,  911 
of  pelvic  outlet,  939 
pregnancy  and,  912 
preperitoneal,  930 
reducible,  913 

symptoms  of,  916 

treatment  of,  916 
sex  and,  912 
sliding,  940 

mechanism  of,  940 

Moschowitz  on,  940,  941 

operations  for,  942 
Hotchkiss',  942 

treatment  of,  942 
spermatic  cord  and,  911 
strangulated,  914 

gangrene  in,  918 

nausea  in,  917 

operation  for,  920 

pain  in,  917 

symptoms  of,  917 

taxis  in,  919 

treatment  of,  919 

vomiting  in,  917 
of  testicle,  700 
trauma  and,  913 
umbilical,  934 


Hernia,  umbilical,  adult,  935 

symptoms  of,  936 
treatment  of,  936 
congenital,  934 

treatment  of,  935 

Oldhausen's     method, 
935 
infantile,  935 

treatment  of,  935 
operations  for,  937 
Blake's,  937 
Mayo's,  937 
varieties  of,  anatomical,  921 

clinical,  916 
ventral,  938 

appendicitis  and,  569 
diagnosis  of,  939 
treatment  of,  939 
Hernie  par  glissement,  940 
Herpes  progenitalis,  689 

treatment  of,  689 
Hey's  operation  for  amputation  at  ankle- 
joint,  963 
Hip  disease,  794 

dislocations  of,  896 

classification  of,  897 
complications  of,  900 
congenital,  966 

diagnosis  of,  967 
osteotomy  in,  968 
treatment  of,  967 
Hoffa's,  967 
Lorenz's,  967 
diagnosis  of,  898 
iliac,  897 

diagnosis  of,  898 
infracotyloid,  899 
perineal,  899 
prognosis  of,  900 
pubic,  897 

diagnosis  of,  898 
sciatic,  897 

diagnosis  of,  898 
supracotyloid,  899 
thyroid,  897 

diagnosis  of,  898 
treatment  of,  900 
tuberculosis  of,  794 

amputation  in,  796 
excision  in,  795 
operation  in,  795 
Sayre  splint  in,  795 
symptoms  of,  794 
Taylor  splint  in,  795 
Thomas  splint  in,  795 
treatment  of,  795 
Whitman       splint      in,      795, 
796 
Hip-joint,  amputation  at,  957 

McBurney's  method  of,  958 
Wyeth's  method  of,  957 
traumatic  arthritis  in,  772 
tuberculous  arthritis  of,  794 
Hirschsprung's  disease,  569 


INDEX 


1003 


Hodgen's  suspended  splint    in   fracture 

of  femur.  s5> 
Hodgkin'a  disease,  291 

treatment  of,  293 
Hoffa's  treatment  of  congenital  disloca- 
tion of  hip,  (.>07 
Holzphlegmon,  389 
Horse-hair  probang,  442 
Hotchkiss'  operations  for  sliding  hernia, 

942 
Hour-glass  stomach,  530 
Housemaid's  knee,  '■'>"'- 
Humerus,  fractures  of,  831 

of  anatomical  neck  of,  831 
of  external  condyle  of,  838 
of  lower  extremity  of,  835 

complications  of,  838 
diagnosis  of,  835 
treatment  of,  838 
operative,  840 
of  shaft  of,  834 

diagnosis  of,  835 
treatment  of,  835 
of  surgical  neck  of,  831 
of  tuberosities  of,  831 
of  upper  extremity  of,  831 

complications  of,  832 
diagnosis  of,  831 
prognosis  of,  832 
treatment  of,  832 
Hydatid  cysts.  98 

of  liver,  573 
of  pancreas.  594 
Hydatiform  mole,  95 
Hydrocele.  695 
acute,  695 
bilocular,  697 
chronic,  695 
chylous,  697 
congenital,  697 
of  cord,  697 
double,  697 
treatment  of,  697 
Hydrocephalus,  364 

treatment  of,  365 
Hydro-encephalocele,  365 

treatment  of,  366 
Hydronephrosis,  633,  634 
intermittent,  634 
symptoms  of,  634 
treatment  of,  634 
x-rays  in,  634 
Hydrophobia.  45 
etiology  of,  45 
morbid  anatomy  of,  45 
symptoms  of,  46 
treatment  of,  46 
Hydrops  articulorum  intermittens,  802 
Hydrothorax,  465 

symptoms  of,  465 
treatment  of,  405 
Hygromata  of  neck,  394 
Hyperchlorhydria  in  gastric  ulcer,  522 
Hypernephroma,  96 


Hypernephroma  of  adrenal  gland,  629 

of  kidney.  627 
Hyperplasia  of  lymph  nodes,  291 
Hyperthyroidism,  404 
Hypertrophic  arthritis,  782 

osteo-arthritis,  7_'7 
Hypertrophy  of  bone,  755 

of  breast,  diffuse  virginal,  487 

of  prostate  gland,  710 
Hypodermoclysis,  152 
Hypospadias,  072 

glandular.  072 

perineal,  672 

treatment  of,  673 
Hypothenar  eminence,  abscess  of,  820 


Ichthyosis  of  tongue,  432 
Icterus,  hemolytic,  598 
Idiopathic    multiple    hemorrhagic    sar- 
coma of  skin,  239 
osteomyelitis,  741 
Ileocecal  tuberculosis,  546 
symptoms  of,  546 
treatment  of,  546 
Ileus,  540 

gastro mesenteric,  519 

mechanical,    abdominal    distention 

following,  186 
paralytic,  abdominal  distention  fol- 
lowing, 185 
Iliac  artery,  ligation  of,  274 
dislocation  of  hip,  879 
Immunity,  28 
active,  29 
passive,  30 
Impacted  fractures,  806 
Imperforate  anus,  723 
Implantation  of  ureter  into  bladder.  645 
Incarcerated  hernia,  914 
Incontinence  of  urine,  071 
Indigo-carmine  test   in   examination  of 

urine,  639 
Indolent  ulcers  of  skin,  231 
Infantile  inguinal  hernia,  922 
paralysis,  323 
umbilical  hernia,  935 
Infection,  surgical  relation  of,  17 

terminal,  28 
Infections,  cryptogenetic,  38 
Infective  granulomata,  34,  35 

ulcers  of  skin,  230 
Infiltration  anesthesia,  169 
Inflamed  hernia,  917 

ulcers  of  skin,  230 
Inflammation,  31 
acute,  31 

alexins  in,  32 
chernotaxis  in,  32 
cicatrization  in,  34 
fever  in,  32 
leukocytosis  in,  32 


1004 


INDEX 


Inflammation,  acute,  loss  of  function  in, 
32 
pain  in,  32 
phagocytosis  in,  32 
pyogenic  organism  in,  32 
redness  in,  31 
resolution  in,  34 
swelling  in,  31 
symptoms  of,  31 
general,  32 
local,  31 
of  bladder,  650 
of  bloodvessels,  248 
of  bone,  741 
of  brain,  359 
chronic,  34 
of  dura  mater,  359 
of  ear,  457 
of  epididymis,  700 
of  face,  388 
of  frontal  sinus,  427 
gangrenous,  56 
of  joints,  770 
of  kidney,  608 
of  lymph  nodes,  281 
of  mammary  gland,  483 
of  maxillary  antrum,  426 
of  mediastinum,  475 
of  membranes  of  brain,  359 
of  muscles,  296 
of  neck,  388 

of  nerves,  307.     See  Neuritis, 
of  pancreas,  588 
of  parotid  gland,  390 
of  penis,  688 
of  pi  a  mater,  360 
of  prostate  gland,  708 
of  rectum,  724 
of  salivary  glands,  433 
of  scalp,  331 
of  scrotum,  688 
of  seminal  vesicle,  706 
of  skin,  194 
of  tendons,  297 
of  testicle,  702 
of  thyroid  gland,  4 1 1 
of  tongue,  432 
of  ureter,  633 
of  urethra,  676 
of  veins,  260.     See  Phlebitis. 
Inflammatory   exudate   in   pericardium, 
241 
stricture  of  rectum,  726 
Infracotyloid  dislocations  of  hip,  899 
Infusion,  intravenous,  of  salt  solution,  151 
Ingrowing  toe-nail,  206 

operation  for,  207 
treatment  of,  206 
Inguinal  hernia,  921 

congenital,  922 
infantile,  922 
Inhaler,  Bennett,  160 

Esmarch,  158 
Innominate  artery,  ligation  of,  270 


Insufflation  anesthesia,  intratracheal,  161 
Intercondyloid  fractures  of  femur,  863 
Intermediate precentral  area  of  brain,  347 
Intermuscular  appendectomy,  564 

Internal  carotid  artery,  ligation  of,  271 

iliac  artery,  ligation  of,  274 
Interphalangeal    joints,  suppurative  ar- 
thritis of,  211 
Interrupted  suture,  145 
Interscapulothoracic  amputation,  956 
Interstitial  appendicitis,  acute,  560 

hernia,  929 
Intestinal  obstruction,  acute,  540 
etiology  of,  540 
intussusception  and,  540 
pain  in,  541 
prognosis  of,  542 
symptoms  of,  541 
treatment  of,  542 
volvulus  and,  541 
vomiting  in,  541 
chronic,  543 

symptoms  of,  543 
treatment  of,  544 
Intestine,  adenoma  of,  550 
bacteria  of,  22 
carcinoma  of,  551 
cysts  of,  550 
diseases  of,  540 
diverticula  of,  546 
acquired,  547 
congenital,  547 
fibroma  of,  550 
large,  hernia  of,  940 
myxoma  of,  550 
obstruction  of,  540.    See  Intestinal 

obstruction, 
operations  on,  553 
papilloma  of,  551 
sarcoma  of,  551 
tuberculosis  of,  546 

hyperplastic,  546 
tumors  of,  550 

symptoms  of,  551 
treatment  of,  552 
ulcers  of,  544 

dysenteric,  545 

treatment  of,  545 
typhoid  perforation  and,  544 
prognosis  of,  545 
symptoms  of,  545 
treatment  of,  545 
Intracanalicular      adenopapilloma       of 
breast,  490 
myxoma  of  breast,  490 
Intracerebral  hemorrhage,  358 
Intracranial  hemorrhage,  356 

neurectomy,  311 
Intramedullary  hemorrhage,  380 
Intraperitoneal  injuries  of  abdomen,  500 
Intrathoracic  goitre,  411 
Intravenous  anesthesia,  166 
Intubation  instruments,  O'Dwyer's,  453 
of  larynx,  451 


IX  DUX 


1005 


Intussusception,    intestinal     obstruction 

and,  540 
Irreducible  hernia,  913 
Irrigating  solutions,  preparation  of,  132 
Ischemic  gangrene,  .">."> 

paralysis,  fractures  and,  810 
Ischiorectal  abscess,  724 
Isthmectomy  in  simple  goitre,  404 


Jacksonian  epilepsy,  367 
Jaundice  in  abscess  of  liver,  571 
in  acidosis,  119 

in  carcinoma  of  gall-ducts,  584 
in  cholelithiasis,  577 
in  pancreatitis,  591,  592 
Jaw,  angioma  of,  436    ' 

bandage,  two-tailed,  141 
diseases  of,  431 
dislocation  of,  876 
bilateral,  877 
diagnosis  of,  877 
treatment  of,  877 
lipoma  of,  436 
lower,  fractures  of,  822 

Gunning's    interdental 

splint  in,  823 
symptoms  of,  822 
treatment  of,  822 
removal  of,  439 
lumpy,  68 

lymphangioma  of,  436 
odontoma  of,  436 
operations  on,  437 
osteoma  of,  436 
osteomyelitis  of,  433 
diagnosis  of,  433 
treatment  of,  433 
papilloma  of,  436 
sarcoma  of,  435 
tumors  of,  434 
upper,  fractures  of,  822 

symptoms  of,  822 
treatment  of,  822 
removal  of,  439 
Joints,  ankylosis  of,  804 

treatment  of,  804 
Charcot's  disease  of,  801 

symptoms  of,  802 
treatment  of,  802 
chondroma  of,  803 
contusions  of,  766 
diseases  of,  766 
dislocations  of,  770 
floating  cartilage  in,  769 
pain  in,  769 
symptoms  of,  769 
treatment  of,  769 
fractures  of,  770 
inflammation  of,  770 
bacteria  and,  771 
chemical  irritation  and,  770 


Joints,  inflammation  of,  etiology  of,  770 

pathology  of,  771 

pyorrhea  alveolaris  and,  771 

trauma  and,  770 
injuries  of,  766 

interphalangcal,  suppurative  arthri- 
tis of,  211 
lipoma  of,  804 
Morton's  painful,  980 
osteoma  of,  803 
sacro-iliac,  tuberculosis  of,  801 
sprains  of,  766 

ecchymosis  in,  766 

pain  in,  766 

symptoms  of,  766 

treatment  of,  767 
syphilis  of,  782 

symptoms  of,  783 

treatment  of,  783 
tuberculosis  of,  783 

amputation  in,  787 

arthrotomy  in,  787 

etiology  of,  783 

operations  in,  787 

pain  in,  785 

pathology  of,  784 

symptoms  of,  785 

toxemia  in,  785 

treatment  of,  786 
tumors  of,  803 
wounds  of,  768 

symptoms  of,  768 

treatment  of,  768 


Kelly's  protoscope,  727 
Keloid  of  skin,  237 
Keyes'  deep  urethral  syringe,  679 
Kidney,  abscess  of,  614 

prognosis  of,  615 
symptoms  of,  615 
treatment  of,  615 
adenoma  of,  627 
angioma  of,  627 
carcinoma  of,  628 
congenital  abnormalities  of,  600 
contusions  of,  603 
cysts  of,  629 

dermoid,  629 
echinococcus,  629 
simple  serous,  629 
dermoids  of,  627 
exposure  of,  639 

oblique  lumbar  incision  in,  640 
posterior    vertical    incision    in, 
639 
fibroma  of,  627 
hypernephroma  of,  627 
infections  of,  ascending,  608 
acute,  610 
hematogenous,  609 

acute  unilateral,  611 


looi; 


INDEX 


Kidney,    infections    of,    hematogenous, 
acute      unilat- 
eral,   diagnosis 
of,  612 
prognosis  of,  613 
treatment  of,  613 
inflammation  of,  608 
injuries  of,  602 

subparietal,  602 
fever  in,  603 
hematuria  in,  603 
pain  in,  603 
prognosis  of,  604 
symptoms  of,  603 
treatment  of,  604 
a>rays  in,  046 
lipoma  of,  627 
movable,  606 

Dietls'  crisis  in,  607 
nausea  in,  607 
pain  in,  607 
prognosis  of,  608 
symptoms  of,  607 
treatment  of,  608 
vomiting  in,  607 
myxoma  of,  627 
operations  on,  638 
papilloma  of,  627 
polycystic,  629 

treatment  of,  (>2!t 
rupture  of,  603 
sarcoma  of,  628 
syphilis  of,  617 

symptoms  of,  617 
treatment  of,  618 
tuberculosis  of,  618 
diagnosis  of,  620 
fever  in,  619 
nephrectomy  for,  621 
pain  in,  619 
polyuria  in,  619 
prognosis  of,  621 
symptoms  of,  619 
treatment  of,  621 
urine  in,  619 
tumors  of,  627 

hematuria  in,  628 
pain  in,  628 
symptoms  of,  628 
urine  in,  628 
wounds  of,  open,  605 
Kinetic  stump  in  amputation,  947 

theory  of  shock,  103 
Knee,  dislocations  of,  901 
backward,  902 
diagnosis  of,  902 
forward,  902 
lateral,  902 
prognosis  of,  903 
rotary,  902 
treatment  of,  903 
tuberculosis  of,  796 
excision  in,  798 
operation  in,  797 


Knee,  tuberculosis  of,  symptoms  of,  798 
Thomas  splint  in,  797 
treatment  of,  797 
Knee-joint,  amputation  at,  959 

bilateral  flap  method  of,  959 
Garden's  method  of,  960 
Gritti's  method  of,  960 
Stoke's  method  of,  960 
traumatic  arthritis  in,  773 
tuberculous  arthritis  of,  796 
Knock-knee,  969 

diagnosis  of,  969 
treatment  of,  970 
Knot,  granny,  144.  145 
reef,  144 

surgeon's,  144,  145 
Kocher's   method   of   reduction   of   dis- 
location of  shoulder,  886 
sign  in  exophthalmic  goitre,  406 
Konig's  spiral  cannula,  451 
Kyphosis  in  Pott's  disease,  789 


Lacerations  of  brain,  356 
Laminectomy  in  fracture  of  spine,  379 

in  operations  on  spine,  386 
Lane's  operation  for  cleft  palate,  421 

suture  in  chiloplasty,  418 
Langenbeck's  operation  for  cleft  palate, 

421 
Laryngectomy,  452 
Larynx,  bacteria  of,  22 
diseases  of,  440 
epithelioma  of,  446 
extrinsic,  446 
intrinsic,  446 
prognosis  of,  447 
symptoms  of,  447 
treatment  of,  447 
fibroma  of,  446 
foreign  bodies  in,  440 

treatment  of,  441 
intubation  of,  451 
operations  on,  449 
papilloma  of,  446 
syphilis  of,  448 
tuberculosis  of,  448 
tumors  of,  446 
wounds  of,  388 
Lateral  anastomosis,  557 

lithotomy  in  vesical  calculus,  663 
Leg,  amputation  of,  961 

fractures  of  both  bones  of,  866 
lower,  fractures  of,  866 
compound,  870 
diagnosis  of,  867 
prognosis  of,  868 
traction  in,  869 
treatment  of,  868 
phenomena  in  tetany,  413 
varicose  veins  of,  261 
Leiomyoma,  85 


INDEX 


1007 


Leontiasis,  755 

treatment  of,  755 
Leptomeningitis,  acute  septic,  300 

lumbar  puncture  in,  301 
paralysis  in,  301 
prognosis  of,  301 
symptoms  of,  300 
treatment  of,  301 
Leukemia,  lymphatic,  293 
Leukocytosis  in  acute  general  sepsis,  39 
inflammation,  32 
pancreatitis,  590 
in  angina  Ludovici,  390 
in  erysipelas,  41 
in  perinephritic  abscess,  017 
Leukoplakia  of  tongue,  432 
Levis'   extension   apparatus   in    disloca- 
tions of  phalanges  of  hand,  890 
Ligation  of  abdominal  aorta,  274 
of  anterior  tibial  artery,  270 
of  axillary  artery,  272 
of  brachial  artery,  273 
of  carotid  artery,  270 
of  common  carotid  artery,  270 
femoral  artery,  275 
iliac  artery,  274 
of  dorsalis  pedis  artery,  277 
of  external  carotid  artery,  271 

iliae  artery,  275 
of  facial  artery,  271 
of  gluteal  artery,  275 
of  iliac  artery,  274 
of  inferior  thyroid  artery,  272 
of  innominate  artery,  270 
of  internal  carotid  artery,  271 

iliac  artery,  274 
of  lingual  artery,  271 
of  occipital  artery,  271 
of  peroneal  artery,  277 
of  popliteal  artery,  270 
of  posterior  tibial  artery,  270 
of  radial  artery,  273 
of  sciatic  artery,  275 
of  subclavian  artery,  271 
of  superficial  femoral  artery,  275 
of  superior  thyroid  artery,  271 

in  exophthalmic  goitre 
410 
of  temporal  artery,  271 
of  ulnar  artery,  273 
of  vertebral  artery,  272 
Ligatures,  144,  145 
in  aneurism,  250 
gangrene  and,  55 
Linea  semilunaris,  hernia  in,  939 

transversse,  hernia  in,  939 
Lingual  artery,  ligation  of,  271 
goitre,  410 
thyroid,  410 
Lip,  epithelioma  of,  397 

treatment  of,  397 
Lipoma,  78 

of  abdominal  wall,  507 
arborescens,  804 


Lipoma  of  bone,  700 
of  chest-wall,  403 
of  face,  390 
of  jaws,  430 
of  joints,  804 
of  kidney,  027 
of  mediastinum,  470 
of  mouth,  430 
of  neck,  390 
of  pharyux,  430 
of  rectum,  730 
of  scalp,  333 
of  scrotum,  092 
of  spinal  cord,  383 
of  trachea,  448 
Lisfranc's  operation  for  amputation  at 

ankle-joint,  903 
Litholapaxy  in  vesical  calculus,  000 
Lithotomy,  lateral,  in  vesical  calculus, 
003 
suprapubic,  in  tumors    of    bladder, 
000 
in  vesical  calculus,  001 
Lithotrite,  Bigelow's,  000 
Littre's  hernia,  919 
Liver,  abscess  of,  571 

symptoms  of,  571 
treatment  of,  572 
adenoma  of,  574 
carcinoma  of,  574 
cirrhosis    of,    ascites    and,    surgical 

treatment  of,  574 
cysts  of,  hydatid,  573 

symptoms  of,  573 
treatment  of,  573 
diseases  of,  570 
ectopic,  570 
gumma  of,  574 
operations  on,  585 
resection  of,  585 
sarcoma  of,  574 
tumors  of,  573 
solid,  574 
Lockjaw,  42.     See  Tetanus. 
Longitudinal  fractures,  800 
Lorenz's  treatment  of  congenital  disloca- 
tion of  hip,  907 
Lower  extremity,  bones  of,  fractures  of, 
852 
of  femur,  fractures  of,  802 
of  humerus,  fracture  of,  835 
leg,  fractures  of,  800 
Lumbar  abscess,  789 
hernia,  940 

puncture    in    acute    septic    lepto- 
meningitis, 301 
in  operations  on  spine,  380 
Lumpy  jaw,  08 
Lung,  abscess  of,  470 

prognosis  of,  471 
symptoms  of,  470 
treatment  of,  470 
actinomycosis  of,  472 
symptoms  of,  472 


1008 


INDEX 


Lung,    actinomycosis    of,  treatment   of, 
472 
carcinoma  of,  474 
decortication  of,  481 
diseases  of,  470 
echinococcus  cysts  of,  475 
prognosis  of,  475 
symptoms  of,  475 
treatment  of,  475 
emphysema  of,  473 
gangrene  of,  472 

prognosis  of,  472 
symptoms  of,  472 
treatment  of,  472 
gummatous  infiltration  of,  474 
sarcoma  of,  474 
syphilis  of,  474 
tuberculosis  of,  473 
tumors  of,  474 

symptoms  of,  474 

treatment  of,  475 

Lupus,  destruction  of  nose  and,  424 

of  skin,  232 
Luxatio  erecta,  884 
Lymph  channels,  diseases  of,  228 
injuries  of,  278 

treatment  of,  278 
obstruction  of,  282 

Filaria    sanguinis    hominis 
in,  282 
nodes,  carcinoma  of,  293 

cervical,  tuberculosis  of,  285 
anemia  in,  286 
•     edema  in,  286 
fever  in,  286 
prognosis  of,  287 
skin  in,  286 
symptoms  of,  286 
treatment  of,  288 
surgical,  288 
diseases  of,  278 
hyperplasia  of,  291 
inflammation  of,  281 
sarcoma  of,  293 
syphilis  of,  290 
tuberculosis  of,  284 
Lymphadenitis,  281 

chronic,  291 
Lymphadenoma,  291 
Lymphangioma,  85,  284 
cavernous,  85 
of  jaws,  436 
of  mouth,  436 
of  pharynx,  436 
Lymphangitis,  281 
pancreatic,  592 
symptoms  of,  281 
treatment  of,  282 
Lymphatic  dilatation,  284 
treatment  of,  284 
leukemia,  293 
nevi,  85,  284 

obstruction,  maerocheilia  and,  284 
macrodactylia  and,  284 


Lymphatic     obstruction,      macroglossia 
and,  284 

system,  diseases  of,  278 
injuries  of,  278 

telangiectasis,  85 
Lymphedema,  282 
Lymphosarcoma,  82,  293 

of  rectum,  732 

of  spleen,  599 
Lysins,  29 


M 


McBurney's  hook,  240 

in  reduction    of   dislocation   of 
shoulder,  888 
method  of  amputation  at  hip-joints, 

958 
operation  for  appendicitis,  564 
point  in  appendicitis,  560,  562 
Mackenzie's  tonsillotome,  430 
Maerocheilia,  lymphatic  obstruction  and, 

284 
Macrodactylia,     lymphatic    obstruction 

and,  284 
Macroglossia,  lymphatic  obstruction  and, 

284 
Macular  syphilide,  62 
Madura  foot,  228 
Main-en-trident,  756 
Malar  bone,  fractures  of,  821 
Malformations  of  breast,  483 
congenital,  of  anus,  723 

of  rectum,  723 
of  urethra,  672 
Malignant  edema,  48 
pustule,  47,  391 
Mammary  gland,  diseases  of,  483 

inflammation  of,  483 
Manubrium  sterni,  dislocations  of,  882 
Many-tailed  bandage,  139 
Marine  sponges,  132 
Mastitis,  acute,  483 

symptoms  of,  483 
treatment  of,  484 
adolescentium,  484 
chronic,  484 
cystic,  488 
interstitial,  485 
treatment  of,  485 
neonatorum,  484 
subacute,  485 
Mastoiditis,  458 

treatment  of,  458 
Mathew's  operation    for  enucleation   of 

tonsils,  430 
Mattress  suture,  145,  146 
Maunsel's  method  of  enterorrhaphy,  556 
Maxilla,  superior,  fractures  of,  822 
symptoms  of,  822 
treatment  of,  822 
Maxillary  antrum,  empyema  of,  42(> 
inflammation  of,  426 
treatment  of,  426 


INDEX 


1009 


Mayo's  operations  for  umbilical   hernia, 
937 
varicose  vein  enucleator,  266 
Meckel's  diverticulum,  547 

Mediastinal  cellulitis,  acute,  475 
symptoms  of,  475 
treatment  of,  476 
thoracotomy,  481 
Mediastinum,  carcinoma  of,  476 
cysts  of,  476 
diseases  of,  475 
fibroma  of,  476 
inflammation  of,  475 
lipoma  of,  476 
sarcoma  of,  476 
tumors  of,  476 

symptoms  of,  476 
treatment  of,  477 
Mediocarpal  articulation,  dislocation  of, 

893 
Mediotarsal  dislocation,  907 
diagnosis  of,  908 
treatment  of,  908 
Medulla  oblongata,  lesions  of,  349 
Medullary  carcinoma  of  rectum,  731 

sarcoma  of  bone,  761 
Melanosarcoma,  84 
Melena,  definition  of,  123 
Membranes  of  brain,  contusions  of,  356 
inflammation  of,  359 
laceration  of,  356 
Meningitis,  359 

cerebrospinal,  360 
Meningocele,  365,  385 
treatment  of,  366 
Meningomyelocele,  385 
Mercier's  coude  catheter,  148 
Metacarpal  bones,  fractures  of,  850 
diagnosis  of,  850 
treatment  of,  851 
Metacarpophalangeal    joints,    suppura- 
tive arthritis  of,  211 
Metallic  catheter,  148 
Metatarsal  bones,  dislocation  of,  907 
diagnosis  of,  908 
treatment  of,  908 
fractures  of,  871 
Metatarsalgia,  anterior,  980 

treatment  of,  980 
Metatarsophalangeal  joints,  amputation 

at,  963 
Midbrain,  lesions  of,  348 
Mid-palmar  space,    infection    of,    treat- 
ment of,  227 
Miliary  aneurism,  249 
Miner's  elbow,  302 
Mirault's  chiloplasty  operation,  418 
Moebius'   sign   in   exophthalmic   goitre, 

406 
Mole,  hydatiform,  95 

vesicular,  95 
Moles  of  skin,  237 

Moore's  dressing  for  fractures  of  clavicle, 
828 
64 


shuing 


Morbus  coxa>,  794 
Morton's  painful  joint,  980 
Moschowitz    on    mechanism    of 
hernia,  940,  941 

operation  for  prolapse  of  rectum,  739 
Motor  area  of  brain,  346 
Mouth,  angioma  of,  436 

bacteria  of,  21 

cysts  of,  434 

treatment  of,  434 

diseases  of,  431 

epithelioma  of,  434 

floor   of,   von   Langenbeck's   opera- 
tion for  removal  of,  438 

lipoma  of,  436 

lymphangioma  of,  436 

operations  on,  437 

osteoma  of,  436 

papilloma  of,  436 

tumors  of,  434 
Movable  kidney,  606 
Mucous  cysts,  97 
Mumps,  433 
Murphy  button,  555 

anastomosis  by,  555 

drip,  186 
Muscles,  atrophy  of,  297 

contusions  of,  294 

diseases  of,  296 

fibroma  of,  297 

hernia  of,  295 

diagnosis  of,  295 
treatment  of,  295 

inflammation  of,  296 

injuries  of,  294 

new  growths  of,  297 

rupture  of,  294 

diagnosis  of,  294 
treatment  of,  294 

syphilis  of,  297 

tuberculosis  of,  297 

tumors  of,  297 

wounds  of,  295 
Muscular  weakness,  fractures  and,  812 
Mycetoma  of  skin,  228 
Myelocele,  385 

prognosis  of,  385 

treatment  of,  385     . 
Myeloma,  80 

of  bone,  762 
Myoma,  85 

heart,  121 
Myositis,  296 

acute  primary,  296 

ossificans,  297 
Myxedema,  operative,  412 
Myxoma,  78 

of  breast,  intracanalicular,  490 

of  intestine,  550 

of  kidney,  627 

of  nerves,  315 

of  rectum,  730 

of  spinal  cord,  383 
Myxosarcoma  of  breast,  491 


1010 


INDEX 


N 


Nail,  199 

base  of,  199 
bed,  201 
body  of,  199 
lunula  of,  200 
matrix  of,  200 
Nasal  bones,  fractures  of,  820 

Adams'  forceps  in,  821 
symptoms  of,  821 
treatment  of,  821 
polypus,  428 

treatment  of,  428 
Nasopharyngeal  polypus,  428 
symptoms  of,  428 
treatment  of,  428 
Nasopharynx,  diseases  of,  422 

tumors  of,  428 
Neck,  actinomycosis  of,  69 
carbuncle  of,  391 

treatment  of,  391 
cellulitis  of,  389 
deep,  389 
symptoms  of,  389 
treatment  of,  389 
contusions  of,  387 
dermoids  of,  392 
diseases  of,  388 
erysipelas  of,  389 
of  femur,  fractures  of,  852 
of  humerus,  anatomic,  fracture  of, 
831 
surgical,  fracture  of,  831 
hygromata  of,  394 
inflammation  of,  388 
injuries  of,  387 
lipoma  of,  396 
sarcoma  of,  398 

treatment  of,  398 
of  scapula,  fracture  of,  827 
tumors  of,  392 
wounds  of,  387 
Necrosis  of  bone,  753 
Nephrectomy,  642 

for  tuberculosis  of  kidney,  621 
Nephritis,  surgical  treatment  of,  630 
Nephrolithotomy,  640 
Nephropexy,  642 
Nephrotomy,  641 

in  renal  calculus,  627 
Nerves,  anastomosis  of,  318 

in  brachial  paralysis,  320 
in  facial  paralysis,  318 
in  infantile  paralysis,  323 
brachial,  paralysis  of,  320 

operations  for,  320 
cervical  sympathetic,  resection  of,  for 
exophthalmic  goitre, 
318 
for  glaucoma,  318 
contusions  of,  303 

symptoms  of,  303 
treatment  of,  303 


Nerves,  diseases  of,  307 

facial,  paralysis  of,  318 

operations  for,  318 
fibroma  of,  315 
fibroneuroma  of,  315 
fifth,    neurectomy   of   first   division 
of,  309 
of  second  division  of,  310 
of  third  division  of,  310 
hernia  and,  910 

inflammation  of,  307.     See  Neuritis, 
injuries  of,  303 
myxoma  of,  315 
operations  on,  318 
sarcoma  of,  315 
stretching  of,  in  neuralgia,  309 

in  sciatica,  309 
tumors  of,  315 

treatment  of,  315 
Nerve  trunks,  compression  of,  306 
symptoms  of,  306 
treatment  of,  306 
wounds  of,  303 

anesthesia  in,  304 
hyperemia  in,  304 
skin  in,  304 
suturing  of,  305 
symptoms  of,  304 
treatment  of,  304 
Neuralgia,  307 

diagnosis  of,  308 

etiology  of,  308 

nerve  stretching  in,  309 

neurectomy  in,  309 

neurotomy  in,  309 

removal  of  Gasserian  ganglion  in, 

311 
syphilis  and,  308 
treatment  of,  308 

injection  methods  in,   311 
Neurasthenia,    diagnosis   of,    from   con- 
cussion of  spinal  cord,  380 
Neurectomy    of    first   division    of    fifth 
nerve,  309 
intracranial,  311 
in  neuralgia,  309 

of  second  division  of  fifth  nerve,  310 
of  third  division  of  fifth  nerve,  310 
Neuritis,  307 

multiple,  307 

optic,  in  tumors  of  brain,  368 
symptoms  of,  307 
treatment  of,  307 
Neuroma,  86 

of  brain,  368 
Neuropathic  arthropathy,  801 
Neurotomy  in  neuralgia,  309 
Nevi,  84 

lymphatic,  85 
Nevolipoma,  267 
Nevus,  267 

skin  in,  267 
treatment  of,  267 
New  growths.     See  Tumors. 


INDEX 


1011 


Nipple,  Paget's  disease  of,  90,  487 

treatment  of,  487 
Nitrous  oxide  as  general  anesthetic,  154 
Nodular  goitre,  400 
Noma,  57,  431 

Normal  salt  solution,  intravenous  infu- 
sion of,  151 
Nose,  bleeding    from,    425.      See    Epis- 
taxis. 
destruction  of,  424 
complete,  424 
lupus  and,  424 
operation  for,  424 
partial,  424 
rhinoplasty  in,  424 
syphilis  and,  424 
trauma  and,  424 
diseases  of,  422 
epithelioma  of,  431 
foreign  bodies  in,  425 
papilloma  of,  431 
sarcoma  of,  431 
tumors  of,  428 
Novocaine  in  local  anesthesia,  169 
Nystagmus  in  tumors  of  brain,  369 


Obliterative  arteritis,  248 
Obstructed  hernia,  914 
Obstruction  of  bowel,  550 

of  lymph  channels,  282 

of  meter,  633 
Obturator  artery,  hernia  and,  911 

hernia,  940 
Occipital  artery,  ligation  of,  271 
Odontoma,  80 

of  jaws,  436 
Odontome,  composite,  436 

fibrous,  436 

follicular,  436 

radicular,  436 
O'Dwyer's  intubation  instruments,  453 
(Esophagus.     See  Esophagus. 
Oidii,  72 
Oidiomycosis,  72 
Oldhausen's    method    in    treatment    of 

congenital  umbilical  hernia,  935 
Olecranon,  fractures  of,  840 
diagnosis  of,  840 
treatment  of,  840 
Olfactory  area  of  brain,  348 
Olive-pointed  bougie,  684 
Operations  for  acute  osteomyelitis,  745 

for  aneurism,  254 

backache   following,    treatment    of, 
179 

on  brain,  371 

for  carcinoma  of  breast,  497 
of  prostate  gland,  721 

for  cellulitis,  196 

for  cleft  palate,  420 

for  destruction  of  nose,  424 


Operations,  discomfort  following,  treat- 
ment of,  178 
for. empyema,  Estlander's,  479 
Fowler's,  481 
Friedrich's,  480 
osteoplastic,  480 
Schede's,  479 
on  epididymis,  716 
on  esophagus,  449 
for  exophthalmic  goitre,  406 
for  femoral  hernia,  932 
on  gall-bladder,  585 
on  gall-ducts,  585 
gas  pains   following,   treatment  of, 

179 
on  genital  organs,  716 
for  hare-lip,  417 
headache   following,    treatment   of, 

179 
for  ingrowing  toe-nail,  207 
for  inguinal  hernia,  924 
for  injuries  of  spine,  383 
on  intestines,  553 
on  jaws,  437 
on  kidney,  638 
on  larynx,  449 
for  lingual  goitre,  410 
on  liver,  585 
on  mouth,  437 

nausea  following,  treatment  of,  180 
on  nerves,  318 

pain  following,  treatment  of,  179 
for  paralysis  of  brachial  nerves,  320 

of  facial  nerves,  318 
on  penis,  716 
on  pericardium,  243 
on  pharynx,  437,  449 
for  piles,  737 
for  Pott's  disease,  792 
preparation  of  dressings  for,  131 
of  instruments  for,  130 
of  ligatures  for,  130 
of  nurse  for,  130 
of  operator  for,  130 
of  patient  for,  129 
of  room  for,  132 
of  silk  for,  130 
of  silkworm  gut  for,  130 
of  silver  wire  for,  130 
of  sponges  for,  131 
of  sutures  for,  130 
for  prolapse  of  rectum,  739 
on  prostate  gland,  716 
restlessness  following,  treatment  of, 

180 
for  s  imple  goitre,  403 
sleeplessness  following,  treatment  of, 

180 
for  sliding  hernia,  942 
on  spine,  386 
on  stomach,  534 
for  strangulated  hernia,  920 
for  tenosynovitis,  223 
thirst  following,  treatment  of,  180 


1012 


INDEX 


Operations  on  thorax,  477 
on  tongue,  437 
for  tuberculosis  of  hip,  795 
of  joints,  787 
of  knee,  797 
of  lymph  nodes,  288 
for  umbilical  hernia,  937 
on  ureter,  638 
for  vesical  calculus,  660 
vomiting    following,    treatment  of, 

180 
for  wounds  of  heart,  246 
Opsonins,  29 

Optic  thalamus,  lesions  of,  348 
Orchitis,  702 

symptoms  of,  702 
syphilitic,  703 
treatment  of,  702 
Orcho-epididymitis,  702 
Osteitis,  741 

deformans,  754 

symptoms  of,  755 
treatment  of,  755 
Osteo-arthritis,  hypertrophic,  777 
Osteo-arthropathy,  pulmonary,  802 
Osteochondritis  in  infants,  783 

syphilitic,  750 
Osteochondrosis,  syphilitic,  68 
Osteogenesis  imperfecta,  756 
Osteoma,  80 

of  bone,  758 
of  chest-wall,  463 
of  jaws,  436 
of  joints,  803 
of  mouth,  436 
of  pharynx,  436 
Osteomalacia,  756 

symptoms  of,  756 
■       treatment  of,  756 
Osteomyelitis,  341 
acute,  341,  741 

colon  bacillus  and,  741 
edema  in,  743 
fever  in,  742 
operations  for,  745 
pain  in,  742 
spontaneous,  341 
etiology  of,  341 
pathology  of,  341 
symptoms  of,  341 
treatment  of,  342 
Staphylococcus    pyogenes    au- 
reus and,  741 
streptococcus  and,  741 
symptoms  of,  742 
treatment  of,  743 
typhoid  bacillus  and,  741 
x-rays  in,  745 
albuminosa,  749 

treatment  of,  749 
chronic,  342,  748 

pathology  of,  342 
symptoms  of,  342 
treatment  of,  343 


Osteomyelitis  of  distal  phalanx,  abscess 
of  distal     anterior    closed    space 
with,  210 
idiopathic,  741 
of  jaws,  433 
non-traumatic,  741 
of  ribs,  463 
subacute,  748 

cortical,  of  septic  origin,  749 

symptoms  of,  749 
treatment  of,  749 
suppurative,  749 
syphilitic,  749 
traumatic,  342,  741 
pathology  of,  342 
symptoms  of,  342 
treatment  of,  342 
tuberculous,  343,  751 
pathology  of,  343 
symptoms  of,  343 
treatment  of,  343 
typhoid,  749 

symptoms  of,  749 
treatment  of,  749 
Osteoplastic  craniotomy,  372 

method  of  amputation  of  thigh,  960 
operation  for  empyema,  480 
thoracoplasty,  480 
Osteotomy  in  congenital  dislocation  of 

hip,  968 
Ostitis  fibrosa,  760 
Otis-Wyeth  urethrotome,  686 
Otitis  media,  457 

symptoms  of,  457 

treatment  of,  458 

Ovarian  dermoid  cysts,  99 


Pachymeningitis,  acute  external,  359 

chronic  internal,  360 
Paget's  disease  of  bone,  754 

of  nipple,  90,  487 
Palate,  adenoma  of,  436 
cleft,  415 

Brophy's  operation  for,  420 
Lane's  operation  for,  421 
Langenbeck's  operation  for,  421 
epithelioma  of,  434 
gummatous  infiltration  of,  436 
sarcoma  of,  435 
Palsies,  traumatic,  306 
Palsy,  infantile  cerebral,  367 
Pancreas,  carcinoma  of,  593 
diagnosis  of,  593 
symptoms  of,  593 
treatment  of,  594 
cyst-adenoma  of,  594 
cystic  degeneration  of,  595 
cysts  of,  594 

hemorrhagic,  594 
hydatid,  594 
pseudo,  594 


INDEX 


1013 


Pancreas,  cysts  of,  retention,  594 

treatment  of,  595 

true,  594 
diseases  of,  588 
inflammation  of,  588 
sarcoma  of,  594 
tumors  of,  593 
Pancreatic  apoplexy,  589 
calculus,  595 

symptoms  of,  595 

treatment  of,  595 
lymphangitis,  592 
Pancreatitis,  588 
acute,  589 

abdomen  in,  590 

dyspnea  in,  590 

fever  in,  590 

leukocytosis  in,  590 

pain  in,  590     * 

prognosis  of,  591 

symptoms  of,  590 

treatment  of,  590 

vomiting  in,  590 
chronic,  592 

diagnosis  of,  593 

jaundice  in,  592 

symptoms  of,  592 

treatment  of,  593 
gangrenous,  589 
hemorrhagic,  589 
subacute,  591 

anorexia  in,  591 

jaundice  in,  591 

nausea  in,  591 

pain  in,  591 
suppurative,  589 
Papilloma,  86 

of  bladder,  665 
duct,  87 
of  intestine,  551 
of  jaws,  436 
of  kidney,  627 
of  larynx,  446 
of  mouth,  436 
of  nose,  431 
of  penis,  692 
of  pharynx,  436 
of  rectum,  730 
of  scrotum,  692 
of  skin,  235 
of  trachea,  448 
of  ureter,  637 
of  urethra,  687 
villous,  87 
Papular  syphilide,  62 
Paracentesis,  477 

pericardii,  243 
Paralysis  in  acute  septic  leptomeningitis, 
361 
in  aneurism,  252 
of  bladder,  671 
of  brachial  nerves,  320 

operations  for,  320 
in  compression  of  brain,  355 


Paralysis,  congenital  spastic,  367 
in  crushing  of  spinal  cord,  381 
in  extradural  hemorrhage,  357 
of  facial  nerves,  318 

operations  for,  318 
fractures  and,  812 
in  hematoinyelia,  380 
infantile,  323 
in  neuritis,  307 
in  simple  goitre,  402 
in  tumors  of  spinal  cord,  383 
Paraphimosis  of  penis,  691 
Parasitic  cysts,  98 
Parasyphilitic  affections,  65 
Parathyreopriva,  413 
Parathyroid  glands,  412 
Paronychia,  204 

treatment  of,  204 
Paronychium,  199 
Parotid  gland,  abscess  of,  390 
treatment  of,  391 
carcinoma  of,  398 
epithelioma  of,  398 
inflammation  of,  390 
treatment  of,  391 
Patella,  dislocations  of,  900 
diagnosis  of,  901 
inward,  901 
outward,  901 
by  rotation,  901 
treatment  of,  901 
fractures  of,  864 

diagnosis  of,  864 
prognosis  of,  866 
treatment  of,  864 
Patent  urachus,  647 
Pelvic  outlet,  hernia  of,  939 
Pelvis,  fractures  of,  825 
diagnosis  of,  825 
treatment  of,  826 
Penis,  cellulitis  of,  688 
chancre  of,  690 
chancroid  of,  689 

treatment  of,  689 
contusions  of,  688 
endothelioma  of,  693 
epithelioma  of,  692 
inflammation  of,  688 
operations  on,  716 
papilloma  of,  692 
paraphimosis  of,  691 
phimosis  of,  690 

circumcision  in,  690 
treatment  of,  690 
sarcoma  of,  692 
tumors  of,  692 
warts  of,  692 
wounds  of,  688 
Perforating  ulcer  of  foot,  317 
Perforation  in  duodenal  ulcer,  526 

in  gastric  ulcer,  523 
Perforative  appendicitis,  acute,  560 
Pericardial  thoracolysis,  244 
Pericardiolysis,  244 


1014 


INDEX 


Pericardiotomy,  243 

for  evacuation  of  a  purulent  exudate, 
243 
Pericarditis,  suppurative,  242 
tuberculous,  242 

treatment  of,  242 
Pericardium,  abscess  of,  242 
aspiration  of,  243 
diseases  of,  241 
foreign  bodies  in,  241 
incision  of,  243 
inflammatory  exudate  in,  241 
injuries  of,  241 
operation  on,  243 
puncture  of,  243 
serous  effusions  of,  241 

treatment  of,  242 
wounds  of,  241 
Perineal  dislocations  of  hip,  899 
hypospadia,  672 
prostatectomy,  719 
Perinephritic  abscess,  616 
symptoms  of,  616 
treatment  of,  617 
Periosteal  sarcoma  of  bone,  761 
Periostitis,  741 

Peripheral  sarcoma  of  bone,  761 
Periproctitis,  724 

symptoms  of,  724 
treatment  of,  725 
Peripyloritis,  530 

symptoms  of,  530 
treatment  of,  530 
Peritoneum,  absorptive  power  of,  508 
actinomycosis  of,  518 
diseases  of,  508 
inflammation  of,  509 
reparative  power  of,  508 
Peritonitis,  acute,  509 
infective,  510 
non-infective,  509 
chronic,  518 
diffuse,  511 

after-treatment  of,  516 
complications  of,  514 
course  of,  514 
cyanosis  in,  513 
diagnosis  of,  513 
fever  in,  513 
hiccough  in,  513 
leukocytosis  in,  513 
meteorism  in,  513 
pain  in,  512 
prognosis  of,  514 
pulse  in,  512 

subphrenic  abscess  in,  514 
fluid  in,  515 
symptoms  of,  515 
treatment  of,  515 
symptoms  of,  511 
tenderness  in,  512 
treatment  of,  515 
tumor  in,  513 
vomiting  in,' 512 


Peritonitis,  generalized,  514 
pneumococcus,  514 
tuberculous,  516 
ascitic,  516 
caseating,  516 
diagnosis  of,  517 
symptoms  of,  516 
treatment  of,  517 
Peritonsillar  ahscess,  432 

treatment  of,  432 
Pernicious  anemia,  598 
Peroneal  artery,  ligation  of,  277 
Pes  cavus,  974 

planus,  974 
Petit's  tourniquet,  254 
Phagedenic  chancroid,  689 

ulcers  of  skin,  231 
Phagocytosis  in  acute  inflammation,  32 
Phalanges  of  foot,  dislocations  of,  908 
fractures  of,  871 
of  hand,  dislocation  of,  895,  896 
fractures  of,  851 

treatment  of,  851 
Pharyngotomy,  Cheever's  lateral,  439 

subhyoid,  456 
Pharynx,  angioma  of,  436 
bacteria  of,  21 
diseases  of,  431 
epithelioma  of,  448 
gummatous  infiltration  of,  436 
lipoma  of,  436 
lymphangioma  of,  436 
operations  on,  437,  449 
osteoma  of,  436 
papilloma  of,  436 
removal  of,  439 
sarcoma  of  449 
tumors  of,  434,  448 
diagnosis  of,  448 
treatment  of,  448 
wounds  of,  388 
Phelps'  hip  splint,  859 
Phenolsulphonephthalein  test  in  exami- 
nation of  urine,  638 
Phimosis  of  penis,  690 
Phlebitis,  260 

diagnosis  of,  260 
infective,  260 
non-suppurative,  260 
plastic,  260 
suppurative,  260 
treatment  of,  261 
Phlegmonous  erysipelas,  41 
Phloridzin  test  in  examination  of  urine, 

638 
Phosphate  calculi,  657 
Pia  arachnoid,  anatomy  of,  335 
mater,  inflammation  of,  360 
Pial  hemorrhage,  358 
Piles,  735.    See  also  Hemorrhoids, 
diagnosis  of,  736 
external,  735 
inflamed,  735 
internal,  735 


INDEX 


101. 


Piles,  mixed,  735 

operations  for,  737 
pain  in,  735 
removal  of,  737 
symptoms  of,  735 
thrombotic,  735 
treatment  of,  736 
radical,  736 
Pirogoff's  operation  for  amputation  at 

ankle-joint,  961 
Plaster  jacket  in  Putt's  disease,  790 
Plaster-of- Paris  bandage,  141' 
Pleura,  diseases  of,  46  I 
endothelioma  of,  474 
tumors  of,  474 
Pleurosthotonus  in  tetanus,  44 
Pneumatic  proctosigmoidoscope,  727 
Pneumectomy,  481 
Pneumococcus  in  infective  arthritis,  774 

in  peritonitis,  514 
Pneumonia,  postoperative,  176 
prophylaxis  in,  176 
treatment  of,  177 
Pneumothorax.  464 
artificial.  477 

avoidance  of,  in  operations  on  lung, 
481 
on  mediastinal  organs,  481 
closed,  464 
open,  464 
symptoms  of,  464 
treatment  of,  464 
wounds  of  chest-wall  and,  460 
Polyarthritis,   chronic  primary  progres- 
sive, 776 
Polycystic  kidney,  629 
Polydactylism,  981 
Polvp,  fungoid  pedunculated,  of  urethra, 

687 
Polyps  of  rectum,  730 
Polypus,  fibrous,  428 
nasal,  428 

nasopharyngeal,  428 
Polyuria  in  tuberculosis  of  kidney,  619 
Pons,  lesions  of,  348 
Pool's  phenomena  in  tetany,  413 
Popliteal  artery,  ligation  of,  276 
"Port-wine  marks,"  267 
Portal  thrombosis,  appendicitis  and,  568 
Posterior  tibial  artery,  ligation  of,  276 
Postoperative  conditions,  treatment  of, 
174 
hemorrhages,  175 
pneumonia,  176 
pulmonarv  embolism,  treatment  of, 

187 
renal  complications,  177 
thrombosis,  treatment  of,  187 
Postrectal  dermoids,  730 
Pott's  disease,  788 

abscess  in,  789 
Bradford  frame  in,  791 
kyphosis  in,  789 
operation  for,  792 


Pott's  disease,  pain  in,  789 
paralysis  in,  790 
plaster  jacket  in,  790 
symptoms  of,  789 
Taylor  brace  in,  791,  792 
treatment  of,  791 
fracture,  867 

Dupuytren's  splint  in,  869 
treatment  of,  869 
Precentral  area  of  brain,  346 
Precipitins,  29 
Presenile  gangrene  54 
Proctitis,  724 

symptoms  of,  724 
treatment  of,  724 
Proctoscope,  Kelly's,  727 
Proctosigmoidoscope,  pneumatic,  727 
Prolapse  of  brain,  366 
of  rectum,  738 
of  ureter,  632 
Prolapsus  ani,  739 

recti,  739 
Preperitoneal  hernia,  930 
Prostate  gland,  carcinoma  of,  715 
operation  for,  72 1 
prognosis  of,  716 
symptoms  of.  715 
treatment  of,  716 
diseases  of,  708 
exposure  of,  717 
inflammation  of,  708 
operation  on,  716 
sarcoma  of,  716 
senile  hypertrophy  of,  710 
catheterism  in,  713 
diagnosis  of,  712 
prostatectomy  in,  714 
symptoms  of,  711 
treatment  of,  713 
urine  in,  712 
tuberculosis  of,  710 
symptoms  of,  710 
treatment  of,  710 
tumors  of,  715 
Prostatectomy,  71s 
perineal,  119 
in   senile   hypertrophy    of   prostate 

glands,  714 
suprapubic,  718 
Prostatic  calculi,  710 

catheter,  148 
Prostatitis,  acute,  708 

diagnosis  of,  708 
symptoms  of,  709 
treatment  of,  709 
chronic,  710 

symptoms  of,  710 
treatment  of,  710 
diffuse,  708 
follicular,  708 
suppurative,  708 
Prostatopelvic  carcinosis,  715 
Proximal  closed  space,  abscess  of,  212 
Pruritus  ani,  729 


1010 


INDEX 


Pruritus  ani,  treatment  of,  730 
Psammoma,  96 

of  spinal  cord,  383 
Pseudo-arthritis,  fractures  and,  812 
Pseudohermaphrodism,  072 
Psoas  abscess,  789 

diagnosis      of,     from     femoral 
hernia,  932 
Pubic  dislocations  of  hip,  879 
Pulmonary      embolism,      postoperative, 
treatment  of,  187 

emphysema,  473 

osteo-arthropathy,  802 
Pulsating  angioma,  252 
Punch  fractures,  850 
Puncture  of  pericardium,  243 
Pus,  definition  of,  35 
Pustulocrustaceous  syphilides,  64 
Pyelitis,  613 

symptoms  of,  613 

treatment  of,  614 
Pyelonephritis,  613 

suppurative,  614 

treatment  of,  615 
Pyelotomy,  641 
Pyemia,  definition  of,  38 
Pylorectomy,  535 
Pyloric  stenosis,  527 

Boas-Oppler  bacillus  in,  529 
diagnosis  of,  528 
symptoms  of,  527 
treatment  of,  529 
Pyloroplasty,  535 

Finney's  operation,  535 
Pylorus,  dilatation  of,  535 
Pyogenic  organisms  in  acute  inflamma- 
tion, 32 
Pyonephrosis,  615,  633 

symptoms  of,  615 

treatment  of,  615 
Pyorrhea    alveolaris,     inflammation     of 

joints  and,  771 
Pyothorax,  465 

symptoms  of,  466 

treatment  of,  466 
Pyuria  in  renal  calculus,  623 

in  vesical  calculus,  659 


Rachitic  rosary,  757 
Rachitis,  756 

constipation  in,  757 

diarrhea  in,  757 

flatulence  in,  757 

symptoms  of,  757 

treatment  of,  758 
Racket-shaped   method   of   amputation, 

951 
Radial  artery,  ligation  of,  273 

bursa,  extension  of  infection  from, 
221 
Radicular  odontome,  436 


Radiocarpal  articulation,  dislocations  of, 

893 
Radio-ulnar  articulation,  inferior,  dislo- 
cations of,  892 
Ratlins,  dislocations  of,  890 
shaft  of,  fractures  of,  842 

complications  of,  842 
diagnosis  of,  842 
treatment  of,  843 
subluxation  of,  891 
upper  extremity  of,  fractures  of,  841 
diagnosis  of,  841 
treatment  of,  841 
Ranula,  434 

Raynaud's  disease,  gangrene  from,  55 
Rectum,  adenoma  of,  730 
angioma  of,  730 
carcinoma  of,  731 
diagnosis  of,  732 
medullary,  731 
scirrhus,  731 
symptoms  of,  731 
treatment  of,  732 
congenital  malformations  of,  723 
stricture  of,  723 

treatment  of,  723 
dermoids  of,  730 

treatment  of,  731 
diseases  of,  723 
epithelioma  of,  731 
fibroma  of,  730 
inflammation  of,  724 
injuries  of,  723 
lipoma  of,  730 
lymphosarcoma  of,  732 
myxoma  of,  730 
papilloma  of,  730 
polyps  of,  730 
prolapse  of,  738 

diagnosis  of,  739 
operations  for,  739 

Moschowitz's,  739 
Whitehead's,  739 
sigmoidopexy  for,  739 
treatment  of,  739 
sarcoma  of,  732 

diagnosis  of,  732 
treatment  of,  732 
stricture  of,  726 
fibrous,  726 
inflammatory,  726 
symptoms  of,  726 
treatment  of,  727 
tumors  of,  benign,  730 
malignant,  731 

treatment  of,  732 
ulcers  of,  728 

actinomycotic,  729 
chancroidal,  728 
non-specific,  728 
simple,  728 
symptoms  of,  729 
syphilitic,  728 
treatment  of,  729 


INDEX 


1017 


Rectum,  ulcers  of,  tuberculous,  728 
wounds  of,  723 

Recurrent  bandage,  136 
Reducible  hernia,  913 

Reef  knot,  144 
Reichman's  disease,  52S 
Relapsing  fever,  chronic,  291 
Renal  artery,  aneurism  of,  605 
hematuria  in,  605 
symptoms  of,  605 
treatment  of,  606 
tumor  in,  605 
anomalies  of,  600 
calculus,  622 

causes  of,  622 
diagnosis  of,  625 
hematmia  in,  623 
nephrotomy  in,  626 
pain  in,  623 
pathology  of,  622 
prognosis  of,  626 
pyelotomy  in,  626 
pyuria  in,  623 
symptoms  of,  623 
treatment  of,  626 
.r-rays  in,  624,  625 
complications,  postoperative,  177 

treatment  of ,  178 
suppuration,  608 
ascending,  608 
acute,  610 
diagnosis  of,  610 
hematogenous,  609 
prognosis  of,  611 
treatment  of,  611 
Resection  of  cervical  sympathetic  nerves 
for        exophthalmic 
goitre,  318 
for  glaucoma,  318 
in  exophthalmic  goitre,  410 
of  liver,  585 

of  ribs  for  empyema,  479 
in  simple  goitre,  404 
Respiratory  anthrax,  48 

passages,  bacteria  of,  21 
Retention  cysts,  97 

of  pancreas,  594 
of  urine,  670 
Retropharyngeal  abscess,  432,  789 

treatment  of,  433 
Reverdin's  methods  of  skin-grafting,  239 
Rhabdomyoma,  85 
Rheumatism,  chronic,  777 
Rheumatoid  arthritis,  777 
Rhinophyma,  428 

treatment  of,  428 
Rhinoplasty  in  destruction  of  nose,  424 
Ribs,  dislocation  of,  883 
fractures  of,  824 

diagnosis  of,  824 
prognosis  of,  824 
treatment  of,  824 
osteomyelitis  of,  463 
treatment  of,  463 


Ribs,  resection  of,  for  empyema,  479 
Rickets,  congenital,  756 
Risus  sardonirus,   1  1 
Roberts'  fracture,  s  1  I 
Rodent  ulcer,  93 

of  skin,  233 
Roller  bandage,  134 
Roseola,  syphilitic,  62 
Round-celled  sarcoma,  82 
Roux's    operation    for    amputation     at 

ankle-joint,  962 
Rubber  drainage  tube,  143 
Rupial  syphilides,  64 
Rupture  of  aneurism,  251,  252 

of  bladder,  648 

of  kidney,  603 

of  muscles,  294 

of  tendons,  294 

of  urethra,  674 


S 


Sacculated  aneurism,  249 
Sacro-iliac  disease,  801 

symptoms  of,  801 
treatment  of,  801 
Saddle-nose,  422 

treatment  of,  422 
Salivary  glands,  inflammation  of,  433 

tumors  of,  398 
Salt  solution,  intravenous  infusion  of,  151 
Salvarsan  in  syphilis,  65 
Saphenous    varix,     diagnosis    of,     from 

femoral  hernia,  932 
Sarcoma,  81 

of  abdominal  wall,  507 

of  adrenal  gland,  629 

of  bladder,  665 

of  bone,  760 

of  brain,  368 

of  breast,  491 

of  chest-wall,  463,  464 

giant-celled,  84 

of  gums,  435 

of  intestine,  551 

of  jaws,  435 

of  kidney,  628 

of  liver,  574 

of  lung,  474 

of  lymph  nodes,  293 

of  mediastinum,  476 

of  neck,  398 

of  nerves,  315 

of  nose,  431 

of  palate,  435 

of  penis,  692 

of  pharynx,  449 

of  prostate  gland,  716 

of  rectum,  732 

round-celled,  82 

of  skin,  238 

of  spinal  cord,  383 

spindle-cell,  83 


1018 


INDEX 


Sarcoma  of  spleen,  599 
of  stomach,  533 
of  suprarenal  gland,  629 
of  testicle,  705 
of  thyroid  gland,  411 
of  tongue,  435 
of  tonsils,  435 
of  ureter,  637 
Sarcomatous  ulcers  of  skin,  234 
Sayre's  dressing  for  fractures  of  clavicle, 
830 
splint  in  tuberculosis  of  hip,  795 
Scalds  of  skin,  189 
Scalp,  abscess  of,  332 

treatment  of,  332 
anatomy  of,  324 
■    avulsion  of,  330 

treatment  of,  330 
burns  of,  330 

treatment  of,  331 
cellulitis  of,  331 

treatment  of,  331 
contusions  of,  326 
healing  of,  327 
hematoma  in,  326 
subcutaneous,  326 
treatment  of,  327 
cysts  of,  dermoid,  334 

pathology  of,  334 
symptoms  of,  334 
treatment  of,  334 
sebaceous,  333 

pathology  of,  333 
symptoms  of,  333 
treatment  of,  334 
diseases  of,  331 
erysipelas  of,  332 

symptoms  of,  332 
treatment  of,  332 
furunculosis  of,  331 

treatment  of,  331 
inflammation  of,  331 
injuries  of,  326 
lipoma  of,  333 

pathology  of,  333 
symptoms  of,  333 
treatment  of,  333 
new  growths  of,  333 
tumors  of,  333 
wounds  of,  328 

gunshot,  treatment  of,  329 
incised,  328 
lacerated,  328 
punctured,  328 
treatment  of,  328 
Scapula,  fractures  of,  826 

of  acromion  process  of,  826 

diagnosis  of,  827 
treatment  of,  827 
of  body  of,  827 

diagnosis  of,  827 
treatment  of,  827 
of  coracoid  process  of,  828 
diagnosis  of,  828 


Scapula,   fractures   of  coracoid   process 

of,  treatment  of,  S2S 
of  glenoid  process  of,  827 
diagnosis  of,  827 
treatment  of,  827 
of  neck  of,  827 

diagnosis  of,  827 
treatment  of,  827 
of  spine  of,  827 

diagnosis  of,  827 
treatment  of,  827 
Schede's  thoracoplasty,  479 
Schlesinger's  sign  in  tetany,  413 
Sciatic  artery,  ligation  of,  275 

dislocations  of  hip,  897 
Sciatica,  nerve  stretching  in,  309 
Scirrhus  carcinoma,  90 
of  breast,  493 
of  rectum,  731 
en  cuirasse,  90 
Sclerosis  of  bone,  753 
Scoliosis,  964 

symptoms  of,  964 
treatment  of,  965 
Scorbutic  ulcers  of  skin,  231 
Scrofuloderma,  287 
Scrotum,  cellulitis  of,  688 
contusions  of,  688 
cysts  of,  692 
epithelioma  of,  693 

treatment  of,  693 
inflammation  of,  688 
lipoma  of,  692 
papilloma  of,  692 
tumors  of,  692 
warts  of,  692 
wounds  of,  688 
Sebaceous  cysts,  97 

of  chest-wall,  463 
of  scalp,  333 
of  scrotum,  692 
of  skin,  235 
Semilunar  bones,  dislocations  of,  893 
treatment  of,  893 
cartilage,  dislocation  of,  770,  903 
diagnosis  of,  904 
treatment  of,  904 
injury  of,  770 
Seminal  vesicle,  disease  of,  706 
exposure  of,  717 
inflammation  of,  706 
tuberculosis  of,  707 
symptoms  of.  707 
treatment  of,  708 
vesiculitis,  706 

symptoms  of,  706 
treatment  of,  707 
x-rays  in,  707 
Senile  gangrene,  53 
Sepsis,  acute  general,  38 

abscesses  in,  39 
albuminuria  in,  39 
chills  in,  39 
diarrhea  in,  39 


INDEX 


1010 


Sepsis,  acute  general,  fever  in,  39 
leukocytosis  in,  39 
nausea  in,  39 
prognosis  of,  W.) 

skin  in,  '-'M 
symptoms  of,  39 
treatment  of,  39 
vomiting  in,  39 
Septic  intoxication,  38 
Septicemia,  38 
Serous  cysts,  97 
Serpiginous  syphilides,  64 
Shaft  of  femur,  fractures  of,  859 
of  humerus,  fracture  of,  834 
of  radius,  fractures  of,  842 
Shock,  101 

alcoholism  and,  104 
anesthetic,  treatment  of,  168 
in  aneurism,  253 
anoci-association  in,  109 
blood-pressure  in,  102 
in  burns  of  skin,  189 
diagnosis  of,  differential,  106 
drugs  in,  107 
etiology  of,  104 
kinetic  theory  of,  103 
morbid  anatomy  of,  103 
prognosis  of,  106 
prophylaxis  in,  108  • 
pulse  in,  105 

in  rupture  of  bladder,  648 
symptoms  of,  105 
treatment  of,  106,  174 
uremia  and,  104 
vomiting  in,  105 
in  wounds  of  heart,  245 
Shoulder,  dislocations  of,  883 
causes  of,  883 
complications  of,  885 
diagnosis  of,  885 
old,  reduction  of,  888 
reduction  of,  by  extension,  885 
Kocher's  method,  886 
McBurney's  hook  in,  888 
subclavicular,  884 
subcoracoid,  883 
subglenoid,  884 
subspinous,  884 
supracoracoid,  885 
symptoms  of,  885 
treatment  of,  885 
tuberculosis  of,  799 
excision  in,  799 

anterior  method,  799 
Kocher's  method,  799 
symptoms  of,  799 
treatment  of,  799 
Shoulder-joint,  amputation  at,  955 
traumatic  arthritis  in,  772 
tuberculous  arthritis  of,  799 
Sigmoidopexy  for  prolapse  of  rectum,  739 
Simon's  chiloplasty  operation,  418 
Sinus,  frontal,  inflammation  of,  427 
Sinuses,  accessory,  diseases  of,  422 


Sinuses  of  brain,  thrombosis  of,  363 
Skey's     operation     for     amputation     ;it 

ankle-joint,  96)5 
Skin,  abrasion  of,  22(.l 

in  acquired  syphilis,  62 

actinomycosis  of,  72,  228 

ainhum  of,  229 

atrophy  of,  in  varicose  veins,  264 

bacteria  of,  20 

blastomycosis  of,  228 

boil  of,  194 

burns  of,  189 

symptoms  of,  189 

treatment  of,  190 
carcinoma  of,  238 

treatment  of,  239 
in  cholelithiasis,  578 
contusions  of,  192 

treatment  of,  193 
cysts  of,  235 

treatment  of,  235 
dermatitis  of,  x-ray,  193 

treatment  of,  194 
diseases  of,  193 
in  elephantiasis,  283 
epithelioma  of,  238 
erysipelas  of,  193 
excoriation  of,  229 
fibroma  of,  237 
fibroneuromata  of,  237 
frambesia  of,  228 
furuncle  of,  194 
guinea-worm  disease  of,  228 
inflammation  of,  194 
injuries  of,  189 
keloid  of,  237 

treatment  of,  238 
lupus  of,  232 
moles  of,  237 
mycetoma  of,  228 
in  nevus,  267 
new  growths  of,  235 
papilloma  of,  235 
sarcoma  of,  238 

idiopathic  multiple  hemorrhagic, 
239 

treatment  of,  239 
scalds  of,  189 
syphilis  of,  228 
in   tuberculosis    of    cervical   lymph 

nodes,  286 
tumors  of,  235 
ulcers  of,  229 

carcinomatous,  234 

chronic,  231 

circulatory,  230 

epitheliomatous,  233 

exuberant,  230 

fungating,  230 

healing,  230 

indolent,  231 

infective,  230 

inflamed,  230 

Marjolin's,  232 


1020 


INDEX 


Skin,  ulcers  of,  phagedenic,  231 

rodent,  233 
sarcomatous,  234 
scorbutic,  231 
secondary  malignant,  234 
sloughing,  231 
spreading,  231 
syphilitic,  231 
traumatic,  230 
treatment  of,  234 
tuberculous,  231 
warts  of,  235 

in  wounds  of  nerve  trunks,  304 
Skin-  and  muscle-flap  method  of  ampu- 
tations, 950 
Skin-flap  method  of  amputations,  949 
Skin-grafting,  239 

method  of,  Reverdin's,  239 
Thiersch's,  239 
Wolfe's,  240 
Skull,  anatomy  of,  334 
diseases  of,  341 
fractures  of,  336 
bending,  337 
bursting,  337 

circumscribed  without  displace- 
ment, 336 
classification  of,  336 
hemorrhage  in,  338 
inner  table  alone,  336 
outer  table  alone,  336 
symptoms  of,  338 
treatment  of,  340 
injuries  of,  336 
osteoplastic  resection  of,  373 
Sliding  hernia,  940 
Sling,  141 

and  chest  binder,  141 
Sloughing  ulcers  of  skin,  231 
Spastic  paralysis,  congenital,  367 
Spermatic  cord,  dilated,  693 
hydrocele  of,  697 
torsion  of,  700 
Spheroidal  carcinoma,  87,  90 
Spica  bandage,  134 
Spina  bifida,  384 

occulata,  385 
Spinal  anesthesia,  170 

cord,  anatomy  of,  374 
chondroma  of,  383 
concussion  of,  380 

diagnosis  of,  from  hysteria, 
380 
from  neurasthenia,  380 
contusion  of,  380 
crushing  of,  incomplete,  382 
transverse,  381 

prognosis  of,  382 
symptoms  of,  381 
treatment  of,  382 
diseases  of,  374 
endothelioma  of,  383 
exostoses  of,  383 
fibroma  of,  383 


Spinal  cord,  glioma  of,  383 
hemorrhage  of,  380 
extradural,  380 
intramedullary,  380 
punctate,  380 
subdural,  380 
injuries  of,  374 
lipoma  of,  383 
myxoma  of,  383 
psammoma  of,  383 
sarcoma  of,  383 
syphilis  of,  383 
tuberculosis  of,  383 
tumors  of,  383 

prognosis  of,  384 
symptoms  of,  383 
treatment  of,  384 
hemorrhage,  380 
Spindle-cell  sarcoma,  83 
Spine,  atlas  of  fracture  of,  378 
axis  of,  fracture  of,  378 
concussion  of,  380 
diseases  of,  374 
dislocations  of,  879 
bilateral,  880 
diagnosis  of,  880 
manipulation  of,  881 
prognosis  of,  881 
treatment  of,  881 
unilateral,  880 
fracture-dislocation    of,    377, 

880 
fractures  of,  374 

laminectomy  in,  379 
symptoms  of,  377 
treatment  of,  378 
injuries  of,  374 

operation  for,  383 
lateral  curvature  of,  964 

symptoms  of,  964 
treatment  of,  964 
operations  on,  386 

laminectomy  in,  386 
lumbar  puncture  in,  386 
of  scapula,  fracture  of,  827 
Spiral  fractures,  806 

reversed  bandage,  134 
Spirocheta  pallida  in  syphilis,  61 
Spleen,  abscess  of,  596 

symptoms  of,  596 
treatment  of,  597 
absence  of,  596 
accessory,  596 
carcinoma  of,  599 
cavernous  angioma  of,  599 
cirrhosis  of,  hypertrophic,  599 
congenital  anomalies  of,  596 
cysts  of,  599 
ectopic,  596 

diagnosis  of,  596 
splenectomy  for,  596 
symptoms  of,  596  * 
treatment  of,  596 
endothelioma  of,  599 


INDEX 


1021 


Spleen,      enlargement     of,     597.      See 
Splenomegaly, 
fibroma  of,  599 

lymphosarcoma  of,  599 
sarcoma  of,  599 
surgical  diseases  of,  596 

tuberculosis  of,  597 
tumors  of,  599 
Splenectomy  for  ectopic  spleen,  596 

for  splenomegaly,  598 
Splenomegaly,  597 
etiology  of,  597 
pathology  of,  597 
splenectomy  for,  598 
symptoms  of,  598 
treatment  of,  598 
Splints  for  fractures,  813 
Spondylitis,  tuberculous,  788 
Spondylolisthesis,  965  * 

symptoms  of,  966 
Sprains  of  joints,  766 
Squamous  carcinoma,  87,  92 
Staphylococcus  in  acute  arthritis,  774 

osteomyelitis  and,  741 
Staphylorrhaphy,  420 
Status  lymphaticus,  111 
diagnosis  of,  113 
in  infants,  112 
in  man,  112 

morbid  anatomy  of,  112 
operative  deaths  in,  113 
symptoms  of,  112 
in  women,  112 
treatment  of,  113 
Steam  autoclave,  132 
Stellwag's  sign  in  exophthalmic   goitre, 

406 
Stenosis  in  duodenal  ulcer,  526 

pyloric,  527 
Sterilizer,  Arnold,  132 
Sternal  end  of  clavicle,   dislocation   of, 

878 
Sternum,  dislocations  of,  882 

of  body  from  manubrium,  882 
symptoms  of,  882 
treatment  of,  882 
of  ensiform  process  of,  882 
symptoms  of,  883 
treatment  of,  883 
fractures  of,  823 

diagnosis  of,  823 
treatment  of,  824 
Still's  disease,  777,  781 
Stoke's  method  of  amputation  at  knee- 
joint,  960 
Stomach,  bacteria  of,  22 
carcinoma  of,  530 
anemia  in,  532 
Boas-Oppler  bacillus  in,  532 
colloid,  531 
diagnosis  of,  532 
emaciation  in,  531 
hemorrhage  in,  532 
pain  in,  531 


Stomach,  carcinoma  of,  prognosis  of,  533 
symptoms  of,  531 
treatment  of,  533 
vomiting  in,  531 
a;-rays  in,  532 
dilatation  of,  519 

diagnosis  of,  520 
symptoms  of,  520 
treatment  of,  520 
diseases  of,  518 
enteroliths  in,  518 
foreign  bodies  in,  518 

symptoms  of,  519 
treatment  of,  519 
hairballs  in,  518 
hour-glass,  530 

gastro-enterostomy  in,  530 
gastrogastrotomy  in,  530 
gastroplasty  in,  530 
treatment  of,  530 
operations  on,  534 
sarcoma  of,  533 
tuberculosis  of,  546 

symptoms  of,  546 
tumors  of,  530 

ulcer  of,  521.     See  Gastric  ulcer. 
Stomatitis,  gangrenous,  431 
prognosis  of,  431 
symptoms  of,  431 
treatment  of,  431 
Stovaine  in  local  anesthesia,  171 
Strangulated  hernia,  914 
Strangulation  of  bowel,  550 
Streptococcus  in  acute  infective  arthritis, 
774 
osteomyelitis  and,  741 
Streptothrix  actinomyces,  68 
Stricture  of  esophagus,  444 
of  rectum,  726 

congenital,  723 
of  urethra,  680 
Struma,  399 

Subacromial  bursitis,  301 
Subaponeurotic  hematoma  in  contusions 

of  scalp,  326 
Subastragaloid  dislocations,  906 
backward,  906 
diagnosis  of,  906 
inward,  906 
outward,  907 
treatment  of,  907 
Subclavian  artery,  ligation  of,  271 
Subclavicular   dislocations   of   shoulder, 

884 
Subcoracoid  dislocations  of  shoulder,  883 
Subcutaneous  abscess,  197 

contusions  of  scalp,  326 
Subcuticular  suture,  146 
Subdeltoid  bursitis,  301 
Subdural  hemorrhage,  358,  380 
Subglenoid  dislocations  of  shoulder,  884 
Subhyoid  pharyngotomy,  456 
Sublingual  gland,  carcinoma  of,  398 
epithelioma  of,  398 


1022 


INDEX 


Subluxation  of  radius,  891 
Submammary  abscess,  484 
Submaxillary  gland,  carcinoma  of,  398 

epithelioma  of,  398 
Subparietal  injuries  of  kidney,  602 
Subpectoral  abscess  of  chest-wall,  462 
Subperiosteal  abscess,  742 

hematoma  in   contusions   of   scalp, 
326 
Subphrenic    abscess,    appendicitis    and, 
568 
in  diffuse  peritonitis,  514 
Subpial  hemorrhage,  358 
Subspinous  dislocations  of  shoulder,  884 
Subungual  space,  201 

abscess  of,  205 
Supernumerary  fingers,  981 
Superficial  femoral  artery,  ligation  of,  275 
Suppuration,  35 
Suppurative  cholecystitis,  580 
osteomyelitis,  749 
pancreatitis,  589 
pericarditis,  242 
phlebitis,  260 
prostatitis,  708 
pyelonephritis,  614 
Supracoracoid  dislocations  of  shoulder, 

885 
Supracotyloid  dislocations  of  hip,  899 
Suprapubic    lithotomy    in     tumors    of 
bladder,  666 
hi  vesical  calculus,  661 
prostatectomy,  718 
Suprarenal    gland,    hypernephroma    of, 
629 
sarcoma  of,  629 
tumors  of,  627 
struma,  630 
Surgeon's  knot,  144,  145 
Surgical  neck  of  humerus,  fracture  of,  831 

technic,  128 
Suture,  chain-stitch,  145 
continued,  145 
interrupted,  145 
mattress,  145,  146 
subcuticular,  146 
through-and-through,  146 
Syme's    operation    for    amputation    at 

ankle-joint,  961 
Sympathectomy  in  exophthalmic  goitre, 

407 
Syncytioma,  95 
Syndactylism,  980 
Synovitis,  chronic,  802 

symptoms  of,  802 
treatment  of,  802 
Syphilide,  macular,  62 
papular,  62 

pustulocrustaceous,  64 
rupial,  64 
serpiginous,  64 
tubercular,  64 
ulcerative,  64 
Syphilis,  61 


Syphilis,  acquired,  61,  62 

chancre,  62 

diagnosis  of,  65 

initial  lesion,  62 

mercury  in,  65 

mucous  patches  in,  62 
tubercles  in,  64 

primary,  62 

salvarsan  in,  65 

secondary,  62 

Spirocheta  pallida  in,  61 

symptoms  of,  62 

tertiary,  64 

treatment  of,  65 

Wassermann  reaction  in,  65 
aneurism  and,  249 
of  bone,  749 
of  breast,  485 
congenital,  61,  66 

Colles'  law  in,  66 

pregnancy  and,  66 

symptoms  of,  67 

treatment  of,  68 
of  cranial  bones,  343 
destruction  of  nose  and,  424 
of  epididymis,  702 
etiology  of,  61 
of  joints,  782 
of  kidney,  617 
of  larynx,  448 
of  lung,  474 
of  lymph  nodes,  290 
of  muscles,  297 
neuralgia  and,  308 
of  skin,  228 
of  spinal  cord,  383 
of  testicle,  703 
tumors  of  brain  and,  370 
Syphilitic  arthritis,  782 
dactylitis,  750 
endarteritis,  65 
epiphysitis,  783 
osteochondritis,  750 
osteochondrosis,  68 
osteomyelitis,  749 
roseola,  62 
ulcers  of  rectum,  728 

of  skin,  231 
Syringomyelocele,  385 


Tachycardia    in    exophthalmic    goitre, 

406 
Talipes  calcaneovalgus,  973 

calcaneus,  974 

equinovarus,  973 

equinus,  974 

valgus,  974 

varus,  973 
Tamponade,  heart,  245 
Tarsal  bones,  dislocations  of,  907 
diagnosis  of,  908 


INDEX 


1023 


Tarsal  hones,  dislocations  of,  treatment 
of,  908 
tuberculosis  of,  799 
Tarsometatarsal  joint,  disarticulation  of, 

963 

Taxis  in  strangulated  hernia,  919 
Taylor  brace  in  Pott's  disease,  791,  792 

splint  in  tuberculosis  of  hip,  79.5 
T-bandage,  139 

Teale's  method  of  amputation,  950 
Telangiectasis,  lymphatic,  85 
Telangiectodes  angioma,  85 
Temporal  artery,  ligation  of,  271 
Tendons,  diseases  of,  297 
dislocation  of,  296 
diagnosis  of,  296 
treatment  of,  296 
extensor,  202 
inflammation  of,  297 
injuries  of,  294 
rupture  of,  294 

diagnosis  of,  294 
treatment  of,  294 
sheaths,  extensor,  221 
infection  of,  215 

diagnosis  of,  222 
relation  of,  to   thenar  and 
mid-palmar  spaces,  220 
secondary  extension  of,  221 
tumor  of,  298" 
wounds  of,  295 

treatment  of,  296 
Tenosynovitis,  222,  297 
operations  for,  223 
Teratoma,  94 

of  testicle,  705 
Terminal  infection,  28 
Testicle,  adenoma  of,  705 
carcinoma  of,  705 
contusions  of,  700 

symptoms  of,  700 
treatment  of,  700 
diseases  of,  699 
ectopic,  699 

treatment  of,  699 
epithelioma  of,  705 
fibrocystic  disease  of,  705 
hernia  of,  700 
inflammation  of,  702 
injuries  of,  699 
sarcoma  of,  705 
syphilis  of,  703 

diagnosis  of,  703 
treatment  of,  703 
Wassermann  reaction  in,  703 
teratoma  of,  705 
tuberculosis  of,  703 
diagnosis  of,  704 
treatment  of,  704 
tumors  of,  705 

diagnosis  of,  705 
mixed,  705 
prognosis  of,  706 
treatment  of,  706 


Testicle,  wounds  of,  700 
Tetania,  413 
Tetanus,  42 

acute,  44 

cephalic,  44 

chronic,  44 

diagnosis  of,  44 

etiology  of,  42 

pathological  anatomy  of,  43 

prognosis  of.  44 

symptoms  of,  44 

treatment  of,  44 
Tetany,  412 

arm  test  in,  413 

Chvostek's  symptom  in,  413 

course  of,  413 

Erb's  test  in,  413 

facial  phenomena  in,  413 

leg  phenomena  in,  413 

Pool's  phenomena  in,  413 

Schlesinger's  sign  in,  413 

treatment  of,  414 

Trousseau's  phenomena  in,  413 
Thenar  eminence,  abscess  of,  220 

infection  of,  treatment  of,  227 
Thiersch's  methods  of  skin-grafting,  239 
Thigh,  amputation  of,  959 

osteoplastic  method  of,  960 
Thomas  splint  in  tuberculosis  of  hip,  795 

of  knee,  797 
Thompson  searcher,  659 
Thoracic  aneurism,  251 
Thoracolysis,  pericardial,  244 
Thoracoplasty,  479 

Estlander's,  479 

Friedrich's,  480 

osteoplastic.  480 

Schede's,  479 
Thoracotomy,  477 

mediastinal,  481 
Thorax,  actinomycosis  of,  70 

operations  on,  477 
Thrombosis,    portal,    appendicitis    and, 
568 

postoperative,  treatment  of,  187 

of  sinuses  of  brain,  363 
Thrombotic  piles,  735 
Through-and-through  suture,  146 
Thymectomy  in  exophthalmic  goitre,  407 
Thymus  in  exophthalmic  goitre,  405 
Thyrodermoids,  730 
Thvroglossal  cvsts,  393 

fistula?,  393 
Thyroid  artery,  inferior,  ligation  of,  272 
superior,  hgation  of,  271 

cartilage,  complete  section  of,  449 

dislocations  of  hip,  897 

gland,  anomalies  of,  398 
carcinoma  of.  411 

treatment  of,  411 

in  exophthalmic  goitre,  405 

inflammation  of,  411 

symptoms  of,  411 

treatment  of,  411 


1024 


INDEX 


Thyroid  gland,  sarcoma  of,  411 
treatment  of,  411 
in  simple  goitre,  400 
tumors  of,  411 
lingual,  410 

secretion,  deficiency  of,  412 
treatment  of,  412 
Thyroidectomy  in  exophthalmic  goitre, 

407 
Thyrotomy,  449 
Thyrotoxicosis,  404 
Tibia,  fracture  of,  S66 
Tibial  arteries,  ligation  of,  276 
Tibiotarsal  dislocations,  905 
backward,  905 
forward,  905 
outward,  906 
symptoms  of,  905 
treatment  of,  906 
upward,  906 
Tic  convulsif,  315 

douloureux,  309 
Toe-nail,  ingrowing,  206 
Toes,  amputation  of,  963 
Tongue,  carcinoma  of,  435 
prognosis  of,  435 
symptoms  of,  435 
treatment  of,  435 
epithelioma  of,  434 
gummatous  infiltration  of,  436 
ichthyosis  of,  432 
inflammation  of,  432 
leukoplakia  of,  432 
operations  on,  437 
removal  of,  437 

von  Langenbeck's  operation  for, 
438 
sarcoma  of,  435 
tuberculous  ulceration  of,  437 
Tonsillitis,  432 

Tonsillotome,  Mackenzie's,  430 
Tonsils,  enlarged,  430 

treatment  of,  430 
enucleation  of,  430 
epithelioma  of,  434 
removal  of,  von  Langenbeck's  opera- 
tion for,  438 
sarcoma  of,  435 
Torsion  of  spermatic  cord,  700 
Torticollis,  316 

treatment  of,  317 
Tourniquet,   Brewer's,   in   amputations, 
945 
Petit's,  254 
Trabeculated  bladder,  68,  71 1 
Trachea,  adenoma  of,  448 
chondroma  of,  448 
diseases  of,  440 
fibroma  of,  448 
foreign  bodies  in,  440 

treatment  of,  441 
lipoma  of,  448 
papilloma  of,  448 
tumors  of,  448 


Trachea,  wounds  of,  388 
Tracheal  dilator,  450 

tube,  450 
Tracheotomy,  449 

tube  in  position,  451 
Trade  bursitis,  302 
Transduodenal  choledochotomy,  587 
Transfusion  of  blood,  149 

cannula,  Crile's,  149 
Transverse  fractures,  806 
Trauma,  destruction  of  nose  and,  424 

hernia  and,  913 

inflammation  of  joints  and,  770 
Traumatic  aneurism,  249 
fractures  and,  812 

cephalagia,  367 

dermoids,  98 

dislocations,  873 

epilepsy,  366 

gangrene,  55 

hemorrhage,  122 

osteomyelitis,  342,  741 

palsies,  306 

ulcers  of  skin,  230 
Trendelenburg's  sign  in  varicose  veins, 

264 
Trephining,  371 
Triangular  bandage,  139 
Trigger-finger,  981 

treatment  of,  981 
Trigonitis,  650 

Trochanters  of  femur,  fractures  of,  852 
Tropocaine  in  local  anesthesia,  171 
Trousseau's  phenomena  in  tetany,  413 
Trunk,  bone  of,  fractures  of,  823 
T-shaped  fractures,  806 
Tubercular  syphilides,  64 
Tuberculosis,  58 

of  ankle,  798 

bacillus  of,  58 

of  bladder,  655 

of  bone,  751 

of  breast,  486 

of  cervical  lymph  nodes,  285 

of  cranial  bones,  343 

diagnosis  of,  bacteriolgical,  60 
biological,  61 

of  elbow,  800 

examination  of  serous  exudate  in,  61 
of  sputum  in,  60 
of  urine  in,  61 

of  fascia?,  299 

of  hip,  794 

ileocecal,  546 

of  intestine,  546 

of  joints,  783 

of  kidnej',  618 

of  knee,  796 

of  larynx,  448 

of  lung,  473 

of  lymph  nodes,  284 

modes  of  infection  in,  60 

of  muscles,  297 

predisposing  factors  in,  60 


INDEX 


1025 


Tuberculosis  of  prostate  gland,  710 

of  sacro-iliac  joint,  801 
of  seminal  vesicle,  707 
of  shoulder,  799 
of  spinal  cord,  383 
of  spleen,  597 
of  stomach,  546 
of  tarsal  bones,  799 
of  testicle,  703 
tubercle  in,  59 
tumors  of  brain  and,  370 
of  vertebral  bodies,  788 
of  wrist,  800 
Tuberculous  arthritis,  785 
of  ankle-joint,  798 
of  hip-joint,  794 
of  knee-joint,  798 
bone-abscess,  751 
dactylitis,  751 
osteomyelitis,  343,  751 
pericarditis,  242 
peritonitis,  516 
sequestrum,  751 
spondylitis,  788 
ulceration  of  tongue,  437 
ulcers  of  rectum,  728 

of  skin,  231 
wart,  231 
Tuberosities  of  humerus,  fracture  of, 
Tubulocyste,  100 
Tumors,  74 

of  abdominal  wall,  507 

of  adrenal  gland,  629 

in  aneurism  of  renal  artery,  605 

of  bladder,  664 

of  bloodvessels,  249 

of  bone,  758 

of  brain,  368 

of  breast,  489 

of  bursa?,  302 

of  chest-wall,  463  _ 

classification  of,  77 

connective-tissue,  77 

epithelial  tissue,  77 

of  esophagus,  448 

etiologv  of,  74 

of  face^  392 

of  gall-bladder,  583 

of  gall-ducts,  584 

innocence  of,  75 

of  intestine,  550 

of  jaw,  434 

of  joints,  803 

of  kidney,  627 

of  larynx,  446 

of  liver,  573 

of  lung,  474 

malignancy  of,  75 

of  mediastinum,  476 

of  mouth,  434 

of  muscles,  297 

of  nasopharynx,  428 

of  neck,  392 

of  nerves,  315 


Tumors  of  nose,  428 
of  pancreas,  593 
of  penis,  692 
of  pharynx,  434,  448 
of  pleura,  474 
predisposing  factors  in,  75 
of  prostate  gland,  715 
of  rectum,  730 
of  salivary  glands,  398 
of  scalp,  333 
of  scrotum,  692 
of  skin,  235 
of  spinal  cord,  383 
of  spleen,  599 
of  stomach,  530 
of  suprarenal  gland,  627 
of  tendon  sheaths,  298 
of  testicle,  705 
of  thyroid  gland,  411 
of  trachea,  448 
treatment  of,  76 
of  ureter,  637 

of  urethra,  687  . 

Typhoid  bacillus,  acute  osteomyelitis  and, 
741 

fever,  ulcers  of  skin  and,  230 
osteomyelitis,  749 

perforation,  ulcers  of  intestine  and, 
831  544 


Ulceration  of  bone,  753 
Ulcerative  arthritis,  782 

syphilides,  64 
Ulcers,  duodenal,  520,  525 
of  intestine,  544 
of  rectum,  728 

actinomycotic,  729 
chancroidal,  728 
non-specific,  728 
simple,  728 
syphilitic,  728 
tuberculous,  728 
rodent,  93 

of  skin,  229  .      , 

of  stomach,  521.     See  Gastric  ulcer, 
venereal,  mixed,  690 
simple,  689 
Ulna,  dislocations  of,  890 
Ulnar  arterv,  ligation  of,  273 

bursa,  extension  of  infection  trom. 
221 
Umbilical  fistula?,  congenital,  50 1 
hernia,  934 

congenital,  934 
infantile,  935 
Upper  extremitv,  bones  of,  fractures  ot, 
826 
of  femur,  fractures  of,  8o2 
of  humerus,  fractures  of,  831 
of  radius,  fractures  of,  841 
Uranoplasty,  419 


1026 


INDEX 


Uremia,  121 

Cheyne-Stokes  respiration  in,  122 
convulsions  in,  122 
shock  and,  104 
symptoms  of,  121 
treatment  of,  122 
Ureter,  cysts  of,  637 
diseases  of,  632 
epithelioma  of,  637 
implantation  of,  into  bladder,  645 
inflammation  of,  633 
injuries  of,  632 
obstruction  of,  633 

symptoms  of,  633 

treatment  of,  634 
operations  on,  638 
papilloma  of,  637 
prolapse  of,  632 
sarcoma  of,  637 
tumors  of,  637 

prognosis  of,  638 

symptoms  of,  638 

treatment  of,  638 
wounds  of,  632 

symptoms  of,  632 

treatment  of,  632 
Ureteral  calculus,  635 

cystoscopy  in,  635 

prognosis  of,  636 

symptoms  of,  635 

treatment  of,  636 

x-rays  in,  635 
Ureterectomy,  643 
Ureteritis,  633 

symptoms  of,  633 
treatment  of,  633 
Ureterotomy,  643 

in  renal  calculus,  627 
Uretero-ureterostomy,  645 
Urethra,  congenital  absence  of,  672 
contusions  of,  674 
cysts  of,  687 
diseases  of,  676 
epithelioma  of,  687 

treatment  of,  687 
foreign  bodies  in,  687 
fungoid  pedunculated  polyp  of,  687 
inflammation  of,  676 
injuries  of,  674 
malformations  of,  672 
papilloma  of,  687 
rupture  of,  674 

symptoms  of,  674 

treatment  of,  675 
stricture  of,  680 

diagnosis  of,  682 

internal  urethrotomy  in,  686 

organic,  680 

spasmodic,  680 

symptoms  of,  681 

treatment  of,  682 

urine  in,  681 
tumors  of,  687 
wounds  of,  674 


Urethral  calculus,  687 
Urethritis,  acute,  676 

diagnosis  of,  677 
prognosis  of,  677 
symptoms  of,  676 
treatment  of,  677 
posterior,  676 
Urethroscope,  electric,  679 
Urethrotome,  Otis-Wyeth,  686 
Uric  acid  calculi,  657 
Urine  in  cholelithiasis,  578 
in  cystitis,  651 
hi  delirium  tremens,  115 
examination  of,  638 
cryoscopy  in,  638 
indigo-carmine  test  in,  639 
phenolsulphonephthalein  test  in, 

638 
phloridzin  test  in,  638 
in  fat-embolism,  111 
incontinence  of,  671 

nocturnal,  in  children,  670 
retention  of,  670 
in  senile    hypertrophy    of    prostate 

gland,  712 
in  stricture  of  urethra,  681 
in  tuberculosis  of  kidney,  619 
in  tumors  of  bladder,  665 

of  kidney,  628 
in  vesical  calculus,  659 


Valentine  irrigating  apparatus,  678 
Varicocele,  693 

diagnosis  of,  694 
symptoms  of,  694 
treatment  of,  694 
Varicose  aneurism,  251 

veins,  261 
Varix,    saphenous,    diagnosis     of,    from 

femoral  hernia,  932 
Veins,  angioma  of,  267 
diseases  of,  260 

inflammation  of,  260.    See  Phlebitis, 
injuries  of,  260 
varicose,  261 

atrophy  of  skin  in,  264 
diagnosis  of,  265 
of  leg,  261 

ring  enucleator  in,  266 
symptoms  of,  264 
treatment  of,  265 
Trendelenburg's  sign  in,  264 
Velpeau  bandage,  modified,  137 
Venereal  ulcers,  mixed,  690 

simple,  689 
Venous  anesthesia,  171 

hemorrhage,  123 
Ventral  hernia,  938 

appendicitis  and,  569 
Vertebral  artery,  ligation  of,  272 
bodies,  tuberculosis  of,  788 


INDEX 


1027 


Vesical  calculus,  657 

cystitis  in,  658 
diagnosis  of,  059 
in  female,  664 
hematuria  in,  658 
lateral  lithotomy  in,  663 
litholapaxy  in,  6(50 
operation  for,  660 
choice  of,  664 
pyuria  in,  659 

suprapubic  lithotomy  in,  661 
symptoms  of,  658 
treatment  of,  660 
urine  in,  659 
varieties  of,  657 
x-rays  in,  659 
Vesicular  mole,  95 
Villous  arthritis,  782 
papilloma,  87 
tumors  of  bladder,  665 
Virginal  hypertrophy  of  breast,  diffuse, 

487 
Visuopsychic  area  of  brain,  347 
Visuosensory  area  of  brain,  347 
Volkmann's  contracture  in  fractures,  810 
Volvulus,  intestinal  obstruction  and,  541 
von  Graef's  sign  in  exophthalmic  goitre, 

406 
von  Langenbeck's  operation  for  removal 
of  floor  of  mouth,  438 
of  tongue,  438 
of  tonsil,  438 
V-shaped  fractures,  806 


W 


Warts,  86 

of  penis,  692 
of  scrotum,  692 
of  skin,  235 
tuberculous,  231 
Wassermann  reaction  in  acquired  syphilis, 
65 
in  syphilis  of  epididymis,  703 
of  testicle,  703 
Watson's    lumbar    drainage    apparatus, 

670 
Weak  foot,  976 
Webbed  fingers,  980 
Wens,  97 

Wet  dressings,  144 
Whale-bone  sound  with  adjustable  ivory 

tips,  443 
Whitehead's   operation  for  prolapse   of 

rectum,  739 
Whitman's  brace  for  flat-foot,  978 

method  of  reduction  of  fracture  of 

upper  extremity  of  femur,  855 
splint  in  tuberculosis  of  hip,  795,  796 
Wilson's  empyema  drainage  tube,  466 
Wolfe's  methods  of  skin-grafting,  240 
Wool-sorter's  disease,  47 
Wounds  of  abdomen,  504 


Wounds  of  bladder,  6  17 

of  bloodvessels,  248 

of  chest-wall,  460 

closure  of,  145 

of  heart,  245 

dressings  for,  143 

of  face,  387 

of  joints,  768 

of  kidney,  605 

of  larynx,  388 

of  muscles,  295 

of  neck,  387 

of  nerve  trunks,  303 

of  penis,  688 

of  pericardium,  241 

of  rectum,  723 

of  scalp,  328 

of  scrotum,  688 

of  tendons,  295 

of  testicle,  700 

of  trachea,  388 

of  ureter,  632 

of  urethra,  674 
Wrist,  amputation  at,  954 

dislocations  of,  892 

tuberculosis  of,  800 
symptoms  of,  800 
treatment  of,  800 
Wrist-joint,  fractures  in  vicinity  of,  843 

traumatic  arthritis  in,  772 

tuberculous  arthritis  of,  800 
Wyeth   method   of   amputation  at  hip- 
joint,  957 


Xanthine  calculi,  658 
X-ray  dermatitis  of  skin,  193 
X-rays  in  acute  osteomyelitis,  745 

in  carcinoma  of  breast,  499 
of  stomach,  532 

in  chronic  arthritis,  780,  781 

in  diagnosis  of  fractures,  809 

in  hydronephrosis,  635 

in  renal  calculus,  627 

in  sarcoma  of  bone,  761 

in  seminal  vesiculitis,  707 

in  subparietal  injuries  of  kidney,  604 

in  tuberculosis  of  bone,  751 

in  ureteral  calculus,  635 

in  vesical  calculus,  659 


Yaws,  228 

Young's  radical  operation  for  carcinoma 
of  prostate,  721 


Zygoma,  fractures  of,  821 


COLUMBIA  UNIVERSITY  LIBRARY 

This  book  is  due  on  the  date  indicated  below,  or  at  the 
expiration  of  a  definite  period  after  the  date  of  borrowing, 
as  provided  by  the  rules  of  the  Library  or  by  special  ar- 
rangement with  the  Librarian  in  charge. 


DATE  BORROWED 


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C28I23B1M100 


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JAN     6  1943  ^pAu-  IfejU^^ 


